Nudge Theory and Tramadol

The MPCC group has called on WADA to ban Tramadol and to impose stricter regulations of corticosteroids in an open letter. The idea is noble but the method of an open letter seems fruitless. What if cycling’s stakeholders could be “nudged” into adopting these measures? This week saw Richard Thaler win the Nobel Memorial prize for economics for his ideas on prompting behavioural changes and maybe there are lessons that can be applied to the pro peloton.

Tramadol is a potent painkiller with side effects from nausea to addiction. There’s no data on its use but speaking to, Slipstream medic Prentice Steffen said “We got a letter back from WADA saying that they were going to continue to watch for [Tramadol] and that they were getting a lot of positive tests for it, particularly in cyclists”. If you need a painkiller this strong then you have a chronic issue that suggests you ought to be taking time off work and probably shouldn’t be racing a bicycle but obviously this isn’t stopping use and abuse.

It is in the peloton’s collective interest to end Tramadol use. If a rider uses a banned substance they may cheat others from success but with Tramadol they put everyone’s health at risk. The medicine comes with advice not to operate heavy machinery and to be aware of effects like blurred or even double-vision, the last thing you want when trying to pilot your way down the Poggio. Bad enough on a solo ride but a risk for a peloton. The MPCC member teams have agreed to avoid it.

Similarly the MPCC has a code for cortisone use. Riders on member teams are not allowed to use it in competition. They test for cortisol and riders with low levels are advised to stop racing. Low cortisol levels are indicative of cortisone doping (and approved cortisone use by a Therapeutic Use Exemption) or 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 could not and therefore the body’s natural ability to recover is endangered. It all makes sense for rider health and helps prevent doping with corticosteroids too.

So why aren’t these things banned? Because not all drugs are banned, they have legitimate therapeutic uses and to ban a drug is to deny its legitimate medical use. There’s the W in WADA, the World and the body covers all sports around the world and so to ban Tramdol and corticosteroids is to stop people in events who may have a real need for it (quite what these are is a headscratcher). Similarly cortisone is difficult to control for, to detect between legitimate therapeutic use in and out of competition, and abuse.

The UCI itself is wary of going above and beyond the WADA Code because it means going out on a regulatory limb, denying medical treatment to athletes that WADA permits is a potential litigation minefield. Plus the UCI has sports politics to think of, stating to the world that the WADA rules are effectively so lax you need to go beyond them may sound virtuous to you and I but in the corridors of the IOC this is hardly going to be well-received.

So what to do?
The self-regulating MPCC is a great idea in theory and a good idea in practice. It gets mocked when teams quit but we ought to mock the teams who sign up to an agenda for the sake of appearances and bail the moment they have to hold themselves to it. But an open letter? This looks like an impotent gesture, as if saying you can’t achieve something but might as well signal your good intentions.

Which brings us to the “nudge theory” aspect. Here is a case where it’s in everyone’s interest to ban these substances but doing so is hard work and technically different. In short it’s difficult and risky to for the UCI to enforce this unilaterally. So make it voluntary but with a twist: teams applying for a World Tour or Pro Conti licence can opt out of cortisol and Tramadol testing conducted by UCI anti-doping at their will, but this decision will be made public. Perhaps when opting out they could publish a statement why too? Similarly test results for low cortisol or the presence of Tramadol will be made public but not bring a sanction. This turns the situation from teams subscribing to the MPCC Group to one where they have to opt out of a UCI policy, it is there right but it puts the onus on them to explain.

Cortisone and Tramadol can be better regulated and even banned but WADA seems reluctant to do this, perhaps it makes perfect sense to regulate their use more in pro cycling but not other sports? So the UCI is caught in a bind, these substances should be regulated more but WADA won’t play ball. The MPCC offers a path out of this but for various reasons teams don’t want to sign up. They may have legitimate reasons but they don’t state why and it leaves many drawing conclusions that they want to arbitrage the rules on cortisone for performance advantages. So how about asking teams to opt out of these tests? This “nudge” changes the status quo, putting the onus on teams to explain when substances like Tramadol are used rather than seeing a few teams adhere to voluntary self-regulation. Will this fix everything? Of course not but nor will an open letter and until WADA acts, softer measures could be explored.

72 thoughts on “Nudge Theory and Tramadol”

  1. Another excellent appraisal of this difficult situation.

    I personally would like to see Tramadol on the banned list. The real problem is that WADA won’t play ball for reasons which remain somewhat obscure. The UCI for once can’t be blamed, as operating outside WADA rules potentially leaves them open to endless and expensive litigation.

    The MPCC group should be congratulated in the present situation within bring the impasse to the forefront. They need to keep banging on the door until such time as someone opens it.

    • How about a complete shift in the list approach?
      Why can’t there be an (admittedly long) list of approved substances and treatments rather than a banned list? With the banned list the authorities are always having to play catch-up with the constant waves of new chemicals and the like, but with an approved list the teams/doctors have to submit proposed treatments and substances and await approval before using…. this would mean a sizable and dedicated team would have to be created by UCI or WADA to ensure timescales are kept short.

      I’m sure there’s reasons why this will prove difficult to make work and it would take quite an amount of time and effort to set up and maintain, but hey, it’s worth the effort to clean up sport isn’t it…?

      • As Inrng pointed out, WADA covers all sports, around the world.
        There’s an article on BBC Sport today, see below –

        Are any professional elite sports performers, particularly when required to perform so frequently, ever 100% ‘fit’? The article suggests not.
        I can well imagine that cycling is no different at all.

        Banning painkillers is part of a larger issue; the other is the workload required of the athlete.
        If the UCI wanted to ban painkillers, go to the root cause – consult with stakeholders and the medics and formally ration total rider km’s (annually, monthly or even weekly?).
        Look at race design better, analyse what stage racing does to the body and how health risks can be reduced…

        We, as fans, are part of the problem too, ever more demanding.

        • Regarding your second paragraph, I’d say that cycling has actually become an “easier” sport through the decades, especially in the last dozen of years. Luckily so, in a sense, although the risk of losing perspective along the way is always there…

          And, well, there’s a good deal of difference when comparing to other sports, where physical contact is part of the game or where traction goes down to the surface directly through your body parts.
          There’s a lot of difference, too, when you think how many of those other sports grew heavier and heavier athletes through the decades, implying greater forces involved.

          The present-day ridden kms as a *medical* reason to take oppiates? Please. It’s not like an aspirin (which you’d better to be careful with, anyway, even if it may *prevent cancer* 😛 ).

          Even fans are less demanding than ever. See the debate about specialisation. I don’t know how you could define “ever more demanding” a world of fans who don’t expect anymore that riders race under the snow or that a TdF champion must test himself in the Classics, too.

          The abuse of pharma, well, it’s all just about… marginal gains – no medical necessity in most cases. Anti-inflammatory drugs *might* make sense, under some circumstances, but painkillers don’t treat any condition, just your perception of it. They’re a cause for increasing damages riders’ health, not a response to it.

          And it still puzzles me: why can’t you just ban Tramadol and let athletes use it, if it’s needed (under God knows what sort of protocol, or under no protocol at all, as it happened with triamcinolone), thanks to a TUE?

          PS Tramadol is a Western sport chemical little friend and it will always be harder to ban than, say, Meldonium.

          • I think I get your general point (and I happen to share your opinion) but surely in the case of Tramadol there is no great commercial interest at stake? It’s available as a number of generics, the profit margin isn’t particularly high and the volume of production that goes to athletes in all sports worldwide isn’t too considerable.

          • “Even fans are less demanding than ever. See the debate about specialisation. I don’t know how you could define “ever more demanding” a world of fans who don’t expect anymore that riders race under the snow or that a TdF champion must test himself in the Classics, too.”

            Some do re: TDF champs – a glance at comments sections says so.

            In any case, would you say that broadly speaking the standard of the peloton has increased, meaning it’s harder to dominate the sport beyond chosen disciplines? That’s what I take from specialistion – everyone is so much better than in the old days. The greats still stand out but the bar is higher.

          • @Eskerrik Asko
            I don’t know about tramadol, but you’d be surprised to know, for instance, how much EPO-related money comes (or came) from the sport. Well, at least I was when I was told some estimates by acquaintances in the medical field. However, I wasn’t referring directly to the economic factor as much as to the political one (also see below). Using some product implies some expertise and, since it’s doping, well, you don’t get all the experimental results published. That’s why forbidden practises usually imply a time gap before becoming widespread and that’s also why the *scientific* use of a drug in sport follows geopolitical or cultural patterns (Meldonium was a great example). It’s not just physical availability, it’s also learning – often directly from in person from already *expert* trainers/doctors – the best way to use the product.

            Please notice the difference between “expectation” and “wish” (or “wishful thinking”). I don’t believe that many fans did actually *expect* Contador or Froome to test themselves in the Classics, even if the former even showed some sign of capability in that sector – which makes his position even worse, for me. Wiggins attempts at the Roubaix have been celebrated, but came someway unexpected. The sheer list of not-just-one-off winners of Monuments and GTs I was commenting about some days ago is telling: one in 22 years. People would have, dunno, stopped watching if their expectations had been betrayed for 22 years or so?
            Hard to say if the peloton level has “increased”, whatever that might mean: if you race less, you’ll obviously go faster. And the “normal” proportion between the two factors can’t be established.
            Racing less mean shorter stages and overall route at the TdF, which used to be (with some exception) some +30% longer then present Tours, for example, but also doing less big races – which obviously take a toll.
            The 1992 TdF (3983 kms) had a similar average speed to 2015 (3360 km) or 2016 (3529 km), despite having an impressive series of over 200 km consecutive mountain stages. But in 1992 40% of the Giro top-ten was later going to the Tour, and 50% of the final TdF top ten had done the Giro (three names with a double top-ten).
            Several of those top ten riders were also racing the Sanremo, the Liège, the Worlds, the Lombardia…
            “But they were doping!”. Sure, and?
            We had great or decent all-around riders both with little doping (due to technical lack of possibilities to hugely enhance performance, not for lack of intentions) and with a good deal of doping.
            Specialisation is more about the way you feel yourself *allowed* to limit your yearly objectives and be considered successful all the same. It’s a cultural factor. Once you limit yourself to less and more specific objectives, you’ll become more effective. Which for sure doesn’t mean you’ve got a “higher level”, and even less so that you’re “better”, we’d need a common benchmark to establish that – but sometimes it doesn’t even mean that you’re faster, imagine that!
            But the higher probability of winning you earn reducing your competitive racing forces the rivals to do the same… and, more often than not, it’s not about “going faster” but about “changing the way a race is shaped”.

            PS Indurain, a rider whose qualities made him perfect for GTs and quite limited in Classics, raced all the same 5-6 Liège getting a couple of top-tens (he also raced as many Sanremos, but with no ambition), he podiumed 3 times in 5 years at the Worlds (the road race, not the ITT), had his decent share of a couple of top tens at the Fleche, won a San Sebastián and showed up several times, albeit with no success at Zurich Metzgete and Amstel. Besides winning his good deal of TdFs, Giros, Pa-Nis, Dauphinés, Voltas and mixed podia. Did he like to race when he barely could win? He knew that racing less would help – in fact, he cut the Giro when he sensed that it started to hinder his Tour chances. Yet, he felt he also should go hard in one-day races and through a good part of the calendar, just because he was expected to do so.

      • Actually, WADA have more or less done that over recent years. Not only are lots of the items on the list followed by phrases like “and other substances with similar chemical structure or similar biological effect(s)”, and other items on the list say “including but not limited to”, but there’s a general catch-all at the start for:

        Any pharmacological substance which is not addressed by any of the subsequent sections of the List and with no current approval by any governmental regulatory health authority for human therapeutic use
        (e.g. drugs under pre-clinical or clinical development or discontinued, designer drugs, substances approved only for veterinary use) is prohibited at all times.

        • Sure, but…
          1) you’ll easily notice how *very* little part of the opioid section of the list goes with that extensive addendum;
          2) the definition of a “pharmacological substance” apparently leaves out a number of products which aren’t even being considered by the WADA, let alone being forbidden or looked for with testing (among them, some of the most debated ones in the field of “sport science”).

      • You can’t have an approved list as it’s impractical to test for “everything else”. There are no magic CSI style machines that will give you a quantitated list of every component on a sample. The laboratories need a list of banned substances so they can design testing methods, it does result in lag when something new comes along but if you want you analysis to be of high quality and hold up in court then thats the only way with current tech.

  2. Your second last paragraph: I’ve been saying that for years – and on these pages.
    To quote myself:
    ‘If WADA won’t ban glucocorticoids out of competition (and tramadol in competition), amongst others, the UCI should ban them themselves.
    If that would be legally difficult to uphold at CAS, all the UCI have to do is say ‘We are banning these drugs in cycling. If you take it and you’re caught we will make that public and ask you to take a voluntary ban’. Teams won’t stomach that – because sponsors won’t.’
    You don’t even need to ban the drugs, just test for them and publish the results, without sanction.
    Most teams would be shamed into complying and those who didn’t, we’d know what they were up to.

  3. The quote above was from:

    Thursday Shorts

    And I’d been saying it earlier:

    As can be seen, I was met mostly with people saying it could not be done (and often outright derision – INRNG described the idea as a ‘PR stunt’).

    The MPCC Exodus

    … if there are legal problems with banning, could the UCI institute the policy of naming any riders found racing on these drugs? It’s not a ban, it’s not a slur, they’re just saying what they found. They could announce that they were going to do this: teams would probably decide not to take the bad PR. (They could do this with all drugs – maybe actually do something to stop the peloton’s rampant, if legal, drug use.)

    I’d have thought that it would be better for the UCI to say ‘We want to ban these drugs, but legally we’re not sure that we can’ and then ask the teams to agree not to use them. Nothing legally binding and no punishment threatened, but then you can name the teams who refuse to agree. The threat of bad PR might dissuade the teams from using the drugs.
    Also – and I’ve no idea if this is legal, but it would also be good to name the riders who then have the drugs in their samples – just naming them, not taking any sanctions. It would be good to have this honesty policy for all substances in all riders’ samples. Maybe that would actually do something about cyclists’ (legal) drug use.

    The Inner Ring February 25, 2016 at 3:58 pm
    What about teams that agree but then sneak pills or liquids to riders? Surely a governing body needs firm rules, not PR stunts.

    Then, those drugs would then be found in the riders’ systems in testing. No punishment, but the public would have a much greater idea of what certain teams are up to. I don’t see that as a PR stunt: it’s transparency. At the moment, we have no idea how prevalent the use of, say, opioids is in the peloton. Better for us to know and it would probably reduce the use. As it is, the teams/riders are using these drugs anyway.

    • Nobody likes person who had right and then proceeds to tell everyone so. (Unless, of course, he also has a steady track report of being in the wrong as often as not and he is not too shy to mention it often enough.)

      Besides, the best acknowledgement of the strength of one’s argument is that one’s opponents adopt it without mentioning it, admitting it or even realising it themselves!

      PS I think the stumbling block is that unless a substance is banned, individual or, I believe, team results cannot be made public, i.e. only anonymous results (such as how many out in a certain race or stage etc).

      PPS The results of pre-competion tests (of a number of athletes chosen by lot) in cross-country skiing (which has a certain limit for hemoglobine levels) are public, but they result in an obligatory DNS status for a few days (which is not an actual ban).

      • I was just wondering why Inner Ring had had such a complete change of opinion between then and now (and thought I’d better back up my claims).
        As you can see on those pages, there was little support for the idea from others and I wondered if that had also changed.

        • My idea is that in the absence of a firm ban teams can still use these things but they have to opt out of the policy. This way everyone signs up not to have recourse to these products by default but they can explain why they as a team don’t want to adhere to the policy.

          • You say:

            ‘teams applying for a World Tour or Pro Conti licence can opt out of cortisol and Tramadol testing conducted by UCI anti-doping at their will, but this decision will be made public. Perhaps when opting out they could publish a statement why too? Similarly test results for low cortisol or the presence of Tramadol will be made public but not bring a sanction.’

            In Feb 2016, I said:

            ‘I’d have thought that it would be better for the UCI to say ‘We want to ban these drugs, but legally we’re not sure that we can’ and then ask the teams to agree not to use them. Nothing legally binding and no punishment threatened, but then you can name the teams who refuse to agree. The threat of bad PR might dissuade the teams from using the drugs.
            Also – and I’ve no idea if this is legal, but it would also be good to name the riders who then have the drugs in their samples – just naming them, not taking any sanctions. It would be good to have this honesty policy for all substances in all riders’ samples. Maybe that would actually do something about cyclists’ (legal) drug use.’

            Those are very similar ideas – but you described my idea above as a ‘PR stunt’.
            My question – and this was my point from the start – is what has changed your mind?

          • So, you’re suggesting that in your idea the UCI wouldn’t publish the riders’ results if the teams opt out of the policy?
            That would be different from my idea where (as I say, if this is legal) they’d just publish the riders’ results.
            But overall, these are similar ideas.

  4. The problem here is the MPCC itself. By insisting on membership and their own rules (most of which actually relate to the empowerment of the self-appointed MPCC management) they create division within the teams. It is also run by management with little to no input from riders.

    If it operated instead as an open forum for teams and riders alike (but not run by them) to discuss doping issues and acted as a lobby group to speak for the sport as a whole it would get more done. With a unified voice tramadol would already be banned. They could also independently audit anti-doping efforts

    MPCC is a good idea badly executed.

  5. I think the “public-shaming” approach may seem like an easy half-way house, but I suspect even that could be open to it’s own legal ramifications.

    I agree that tramadol use in the peloton is dangerous and should be banned, but the governing body attempting to publicly shame a rider for doing something that’s perfectly within their own rules, seems somewhat duplicitous as well as a gross invasion of the athlete’s privacy.

    Is there any kind of precedent for this sort of behaviour from a governing body before?

    • I couldn’t say but I’d doubt that any precedent might exist for the simple reason that until very recent years the WADA wasn’t considered such a decisive entity (and it didn’t even exist 20 years ago).

      Anyway, on a different level but with a similar perspective of conflicting norms, the Italian CONI launched the “Io non rischio la salute” (“I don’t put my health at risk”) campaign which enforced a series of tests with sort of a rudimentary bio-passport and other available-but-not-currently-practised antidoping lab tests.
      In 1999, cycling teams were asked to participate on a voluntary basis and most refused, Mapei the more notable exception. Pantani was vocal against the programme for the reasons which many share here about forbidding or discouraging Tramadol in cycling only.
      Just before the Sydney Olympics, where all Italian athletes were forced to take part in the programme, the scientific commission alerted that even if everything was fine according to the then valid antidoping norms, worrying blood fluctuations could be detected in the values of several athletes. No names were officially made public, but apparently it was the CONI which happily leaked – only – Pantani’s name.
      Less than two months later the commission made public a study which revealed that the “Io non rischio la salute” tests showed that five golden medal winners in Sydney probably used GH hormone.
      The CONI nearly immediately suspended every activity of the commission and the programme “due to the damage caused to Italian sport, its athletes and managers”.

      A very good example of what antidoping, as a science, is for sport institutions. Useful to disciplinate conflict at any level, subordinate to political interests of various nature.

      • Pantani’s reasons may have *ostensibly* been the same as those expressed here, but it’s quite possible that he had other reasons for being against anti-doping measures that aren’t as widely shared!

  6. Is the issue solely with Tramadol ?
    It’s an opioid – doesn’t the same problem apply to others ? They all to varying degrees all have same issues of affecting your alertness and causing double-vision, etc.
    And all have issues of user addiction, drug abuse in the ‘druggie’ sense, overdosing risks of death, etc

    • Several opioids are indeed forbidden and have a history of doping DSQ around them, hero1n, m0rphin3 and c0de1ne are infamous in cycling… the latter now being out of the WADA list!
      Well, I guess that once you’ve got one or two *legal* product that *work decently* you don’t need to look further.

    • Tramadol does seem to have become the poster boy for borderline cheating, see for example Nicole Sapsted of UKAD vowing to investigate Tramadol use by Team Sky and British Cycling for using Tramadol (which, seeing as it’s not a banned substance would be outside UKAD’s investigative authority, so it’s really clear what she was on about, other than grandstanding in front of the MPs in the DCMS).

      The esteemed INRG seems to have the same doubts: “and so to ban Tramdol and corticosteroids is to stop people in events who may have a real need for it (quite what these are is a headscratcher)”

      One credible “real need” in cycling for an opioid like Tramadol would be in a stage race where a rider has crashed and needs pain relief to enable overnight rest. Clearly, given the side effects, its effects should never be active when a rider’s on the start line, but for many of these borderline substances, there are legitimate applications. Unfortunately, that’s where the cheating comes in.

  7. Just to follow up my previous sentence replying to Adam…
    “A very good example of what antidoping, as a science, is for sport institutions. Useful to disciplinate conflict at any level, subordinate to political interests of various nature”.

    WADA itself, for instance, eventually became a tool to change power balance within IOC… which was becoming a little too much third-World friendly (relative to its historical right-wing nature, I mean).

    The weight of Africa in the WADA in economic terms is barely significant and its representation is notably reduced, too, when compared to IOC. Same goes for Asia, even if it’s less evident: but one should also note that what’s called Asia was really a club of ten countries (Japan, China, India, Iran, South Korea, Malaysia, Pakistan, Qatar, Singapore, and Thailand) with the rest paying a 5,000$ fee until five years ago or so when the situation slightly changed – but not much.
    To put this into a little perspective, imagine that Oceania has got TWO governs as representatives, New Zealand and Australia, while Africa has 3 and the whole Asia has 4. Sure, Oceania pays way more than Africa (2.5% of the total against 0.5%), but Asia is paying 20% of the bill…
    In money terms, “Americas” are 75% USA and Canada, with USA paying 50% of the whole “Americas” amount and being by far the stronger single contributor.
    A very interesting aspect is that while Europe is paying nearly half of the total bill, the European funding isn’t managed at a national level but at EU level, by the Council, which means that it’s harder for single nations to use money as a political leverage.
    No Russia, obviously enough.

    Government representation is allocated according to the five Olympic Regions. Let’s have a look to the representative for each “continent”, and let’s try to imagine the relative weight they might have… in Europe, the six represented “countries” are: Norway, the *Flemish side* of Belgium (!), Turkey (!!), Malta (!!!), the Secretary of the European Council (what the…?) and – the United Kingdom.
    Asia is Japan, China, South Korea and Saudi Arabia.
    Africa is Gabon, Kenya, Namibia.
    And “Americas”? USA, Canada, Dominican Republic, Colombia and Venezuela.

    Guess how the political balance work? No Brasil, no India, no Russia nor ex Sovietic Republics of sort, no Arab Africa (a generally quite weak Africa, with a couple of 2M inh. states).

    Is WADA the new NATO or what?

    This is a very general picture about the national weight of different nations in terms of funding and government representation. The specific persons who work there might be of different nationalities, but they’ve been chosen by the nations above, or this is what I understand: “The governments of each respective region are responsible for the process of electing members to WADA’s Foundation Board and Executive Committee and notifying WADA of the appointments” (for example, there’s a member from Fiji which must have been selected by Australia or New Zealand, I guess).

    But let’s get less geoconspiranoic and let’s get down to what interests us in the practice.

    The prohibited substance list is being worked through by a specific expert group of 13 persons: 4 are from USA, 4 from UK (two with double nationality, shared with Switzerland and Ghana), one is Irish, one is Australian, 2 are from Germany and the last is from the Netherlands.
    The TUE group? 9 persons. USA, UK, Canada, Australia, New Zealand, South Africa, Finland, Norway and Singapore.

    Sure, you’ve got several representatives from other countries (following the principles which derive from the main picture) in the “political” chairs, a lot of Italy, a good deal of Germany, some France, a bit of Turkey, China or Japan, but if you want to know who writes down what should be in the list and what doesn’t, how a TUE works, if it’s to be conceded or not, well, the experts group which provide for tecnhical guidance are from those countries.

    And that’s how WADA can be used to change the IOC equilibrium… 😉

    • As long as the experts are free from political influence and are genuinely expert it will not matter where the come from. Of course many sports governing bodies, both international and national, have a poor record with regards to political interference and as state funded institutions are always vulnerable.

      In free markets it is of course mainly commercial organisations that ‘nudge’ and as I understand it effectiveness depends on somewhat more subtlety than naming and shaming.

      • “As long as the experts are free from political influence and are genuinely expert it will not matter where the come from”.

        Sure. And markets will self-regulate as long as a series of miracle-like conditions will prove themselves true (but we can always pretend *they are* and act *as if*, can’t we?) .

        The nationality of the experts becomes relevant when you notice within which economic and “governance” framework they’re working. The results are just too coherent with such premises.

        While the CONI scientific commission I cited above was doing its work (freely and competently, in that case, indeed), and that work happened to be *useful* for the managing body interests – especially when translated into appropriate leaks – the experts received public clapping; when in a few weeks time the experts themselves discovered that part of their work was being kept away from the public eye and hence leaked something themselves, something which wasn’t as useful and politically opportune as the previous piece of work, they were blamed and every activity suspended. And it’s not an “Italian thing”: the UCI bio-passport has gone through similar circumstances in more recent years.

        • That is perhaps where the scientist differs from the administrator – the scientist has pride in the accuracy and credibility of their work whilst the administrator is perhaps more pliable. The scientist must be kept involved and WADA has some, albeit limited, supply of political operators to keep the other administrators at bay. I will not argue the virtuosity of all scientists but (I have no evidence to cite) are more whistle-blowers scientists than administrators?

    • Who is in the expert group?

      One interesting aspect is that the sport scientists who make the technical decisions at WADA, may themselves have interests in coaching athletes. I have met a leading sports scientist who has been on the WADA expert group, who has done WADA funded anti-doping research, and they like to advertise how they regularly coach/advise top athletes (inc. one world famous athlete).

      Ever since then, I have wondered to what extent WADA is about allowing the poachers to also be the gamekeepers.

      • Oh, it is worth considering the economics of the incentive structures in sports science – esp. at the top of that field. It is surely a major factor in doping. (E.g., look at the history of the guy who developed the EPO test).

        The sports scientists must obtain funding to practice their science. The most reliable vein of funding is from the athletes, and the most successful athletes have the most to spend. They will go to the sport scientists who have the best current knowledge. The sport scientists with the best current knowledge, are those with the best current knowledge of how to push the limits within the current regulatory regime (knowing where regulation is weak, or ill-defined). The sports scientists who are /involved/ in overseeing the regulation – setting it and/or monitoring effectiveness – have the best knowledge in that area. Etc.

        As ever, it all comes down to the economic incentives in the sport. Much attention has been paid to those of the riders, teams and the sports regulators (UCI, etc.). I think the incentives of the sports scientists, who operate more behind the scenes, has been overlooked and could do with some attention.

      • Excellent insight.
        I didn’t dwell into who the persons exactly were (I had spent enough time on the organisational aspects already 😉 ). But you can easily find the names on the WADA website.

  8. Thanx all for insightfull inputs(WADA-NATO??) very anglo indeed..

    I am against doping in cycling and sports in general, first and foremost because I want to know who my champions are, I cheer for Nibali descending and Albertus attacking, and I would hate to have these memories broken by realizing in some future that they were “cheats”.

    I think we should all be against doping for the general health of the athletes, although I guess one could argue that it would imply the end of pro cycling as we know it.

    Many good arguments have been around this site during the last years when I have been reading.
    It seems sensible to ban the Tramadol use, but is it not likely that something similar will be taking its place really fast?

    What about the doctors roles within teams, would it be possible that the doctors were working for WADA and not the teams (TUE extension) – so that any treatment would be dealt with by a impartial propessionels.

    Finally could it be possible that we as fans, points equally towards the sponsors rather than the riders who cheats? – How many doping cases did ride Specialised bikes during the last 5 years, same thing for Shimano etc.
    I think one mayor stakeholder in pro cycling, the industry could/should take a stronger stand.

    I really appreciate reading in here, both the posts and comments!!!

  9. WADA’s prohibited list has 3 categories:
    – Prohibited at all times
    – Prohibited in-competition
    – Prohibited in particular sports

    Why is it so difficult for cycling to make use of the latter category if it is genuinely considered a sport specific health and safety issue?

      • The criteria/rationale is the same and it is certainly within the WADA Code to do it:

        “4.2.1 Prohibited Substances and Prohibited Methods

        The Prohibited List may be expanded by WADA for a particular sport.

        If Tramadol, in the context of the sport of cycling, meets the criteria for being added, then I don’t see why not.

        Else how did the items currently in that section of the prohibited list get there? Surely there is a discussion between those specific sports and WADA?

        • I think the shooting and driving sports have additional banned items, not because they’re performance enhancing but just dangerous. The question is whether opiate-based painkillers are equally dangerous in cycling.

          Long-term, I wonder if we’re heading to a situation where riders are forced to retire after crashing, to reduce the need for pain-killers? (And also to avoid the chances of concussion.)

  10. “Naming and shaming” is rarely a magic wand. It has a number of well-known problems, some of them legal, which are rehearsed regularly in many different contexts.

    In this case, are there not similarities to be drawn with the blood bags in Operacion Puerto? The anti-doping authorities have them now, they can identify to whom they belong, but no names are forthcoming.

    Breaches of “medical confidentiality” and “human rights” do have a way of keeping m’learned friends both occupied for substantial periods of time and rolling in oodles of cash.

    • Quite so. The UCI is not a rich body. To go shooting their mouths of in regard to currently legal substances might make them considerably poorer. Its much easier for people posting on a blog to say “Why don’t they name and shame?” because its not them who may be bankrupted.

  11. As a surgeon, let’s first have a reasonable discussion on pain management. So if tramadol is out, opioids, gone. No needles means marcaine and lidocaine gone. Please list what these poor riders are allowed to use? Riders fall and essentially are going to be denied pain management.

    • If the pain is that bad it requires narcotics, should the athlete continue?

      For stuff that is bad – medical emergency treatment is detailed in the WADA code and substances necessary to administer which on the prohibited list are handled with Retroactive TUEs:

      “A medical emergency or acute medical situation occurs when the athlete’s medical condition justifies immediate Administration of a Prohibited Substance or Method and failure to treat immediately could significantly put the athlete’s health at risk. It is always preferable to address a TUE application prospectively rather than retrospectively. ADOs granting TUEs should have internal procedures to expedite the evaluation and granting of TUE for emergency situations, whenever possible, and without putting the athlete’s health at risk.”

    • No one will deny athletes medicines with medical need.

      The issue is that medical conditions that need certain medicines are incompatible with taking further part in sport, for some amount of time. If you are in severe pain, to the extent you need opiates, you shouldn’t be cycling – the athlete clearly needs to recover, and the rest of the peloton do not need a drowsy, drugged rider in their midst.

      • It seems that today we want cycling where you may crash badly, be in considerable pain but want to continue… and you are left to do so without pain relief or are told, very much contrary to the romantic notion we have of cycling from its beginnings, that you have to stop.

        Is this progress?

    • 3 recent surgical procedures and zero need for opioids . Other options exist, such as naproxen sodium. And it does not retard healing. Your patients need to read about rule 5!

  12. And the comment that a rider who uses tramadol must have a chronic injury requiring rest Is just laughable. Please, what’s acceptable treatment of acute injury?

    • You’re a medical doctor. If you think your patient needs a medicine for some acute injury, that’s entirely down to you.

      You are not, however, the primary stakeholder in the sports ethics and safety side. That would be the other riders. Further, as a medical doctor, you have no more expertise in that side than others.

    • It seems you’ve read things the wrong way, it’s not a choice of rest or opiates for someone in pain. It’s more that someone with chronic pain requiring such a powerful drug probably should not be doing a long bike race.

      • People in pain should stop? What happened to our cycling narrative since cycling began of brave warriors riding 10 hour stages through wind and rain, up mountains, down snowy gorges, tyres over their shoulders and inner tubes in their wool jerseys?

        Have we come down to “if you’re in pain stop”?

  13. Really? Listening to the ameturish discussion around the implications of tradmadol are a bit annoying. As one of the few people here who has prescribed it, and not withstanding your opinion, I have a very good understanding of the issues with the drug. As a surgeon I’ve used the drug, and feel comfortable with it’s use. The point of the discussion should be more on acceptable use parameters. Simple banning medications, and waving the ethical flag, with an internet research level of knowledge does not further the discussion.
    A great example would be Jan Bakelants, with opioids on the way out, tramadol now close to being on the banned list, what do you suggest his physicians treat his spinal fractures and not raise red flags? Or will his TUE raise future red flags?

    • @Joe G
      While you might be a very competent surgeon, your insight about cycling rules looks quite limited, as Alex pointed out above (among other things).
      Note how that doesn’t prevent you from forming and spelling out an opinion about the main subject here, which is more related to the rules of the sport rather than to the *medical* use of a substance.

      (By the way, I’ d say that you haven’t until now expressed clearly why tramadol would be a good option to take care of riders’ health *while they go on riding* and *in absence of objective reasons to grant a TUE*)

      Cyclists can use pretty much any sort of forbidden substance, provided that they use the existing protocols which has been specified above, both in case of acute injuries and emergencies.

      I don’t know – not a specialist at all – but I’d be ready to bet that Bakelants during these last weeks is being treated with a variety of some *forbidden* drugs, and he won’t endure any trouble with sport’s rules for that.

    • @Gabriele and @Joe G

      Gabriele – exactly, Joe’s missed the point entirely. Obviously Bakelants is likely being treated with things that are banned in competition or on watch list, etc. The point is, Bakelants IS NOT IN COMPETITION! So while it is essential to use correct medication to treat illnesses/injuries/serious conditions the point is that many of these drugs have side effects which can enhance performance.

      Joe – Therefore, use whatever drugs you have to to treat Bakelants’ spinal fractures, pain, etc. However, if he has to take some of these drugs while in competition, then any educated person can see that he must not be fit enough to return to competition. Some of the drugs noted in this discussion, such as Tramadol, have significant side effects that can a) enhance performance and b) make it dangerous for the rest of the peloton. Either you are arguing for the sake of arguing (which is fine, but please admit it!) or you are missing this very important aspect.

      I’m not a surgeon, pharmacist or other healthcare professional. However, I am highly educated, a past athlete who raced at a very competitive level and a student of the sport. Like many people reading Inrng’s blog, I consider myself very well versed on the ethical and practical issues at play.

      Bottom line, if you have to use many of these drugs to compete, you’re clearly not fit/healthy enough to compete and rest is necessary. Cycling and sport in general have this mentality that you race/play at any costs, well in 2017 that mentality does not work anymore!

      • +1 Too many fail to make any distinction between life and sport. Sport, unlike life is entirely artificial and governed by purely arbitrary rules. Someone who argues for the use of something like Tramadol in LeTour might as well argue that using a motorcycle is OK too.

  14. In fact, all TUEs should be open. However, not sure this is in-line with personal medical history privacy. Maybe we can publish at least which WT team applied for how many TUEs during a given time period.

    On the other hand, an argument can be made to make Tramadol usage public at least within the peloton. One can potentially endanger other riders using such a strong painkillers that significantly affects their handling especially on a descent. Thus, other riders has a right to know who is on it.

  15. I don’t know for sure but I think that in my country driving while taking these kind of drugs (which explicitly warn about the side effects affecting your ability to drive) has legal implications. Of course there are no roadside tests for it but I believe (might be wrong, IANAL) that if you are involved in an accident and it comes out that you were on such a drug the penalty is similar to drunk driving.
    I think it would make total sense to ban such drugs specifically for road racing since it was mentioned above that that is possible. For tennis or swimming, or even ITT, it would be a different story since you are not endangering others.
    I don’t really buy in to the ‘if you need this drug you should not be on the bike’ argument. We are talking about top level professionals here. Imagine e.g. you’re a lawyer on the day of an important court case waking up with a splitting headache. Of course it’s better to stay in bed but you take whatever painkillers you have in the bathroom closet and go to work to get the job done. That’s what I do too and I have a job with a fixed salary and fully paid sick leave. A rider whose career depends on riding and or winning certain races should be allowed the same choice. But not if it endangers others.

    • You won’t find any statistics or analysis of accidents, near misses or safety in cycling however.
      If its rules are arbitrary, then so is its methodology.

      And does Tramadol, for instance, have the same effect on an individual who is sweating and drinking profusely, engaged in ultra-strenuous activity that requires several thousand calories burned off to do it? Maybe not.
      Or equally, are its effects more dangerous, even temporarily, on an individual who is physically stressed and may be considered, to some degree, immune-suppressant?
      We don’t know. Nor do we know if the drug has performance-enhancing capabilities.
      Lappartient is a politician, and plays the risks, and it will be very interesting to see where this subject goes.

      • Given that a good number of riders in the peloton are taking the substance, far more than those who could suffer from any specific medical condition, I’d dare to say that some marginal gain is up to grab.
        Moreover, even if the UCI might not be famous for its scientific approach (nor is WADA), some big teams are indeed proud of their sport science: since they’re precisely among the reported tramadol abusers, I’m confident that they’re doing it because it enhances performances more than it hinders them (obviously, athlete health, esp. in the middle to long term, doesn’t factor in: for the team it’s totally marginal… and it’s not a gain).
        You don’t have to be 100% scientifically sure about a substance to ban it: imagine that recent studies cast doubt about the effectiveness of EPO in boosting performances. Should we reconsider allowing it?
        People shouldn’t be taking drugs to practise a pro sport. A greater degree of certainty is needed to *allow* some of them as an *exception*, not to exclude their use.

        • My point was, linked to above, that the effort required from riders, especially in stage races, is never a constant. It can seriously vary according to arbitrary course design, weather, tactics etc.
          An elite runner by comparison pretty much knows what is required of performance as it’s a constant.

          So, it’s the concept of ‘pain’ in cycling that interests me.
          If it’s never a constant, and is relative anyway, how can a safe threshold be known or set?
          This is not to say that drugs should be allowed, only that the workload required of the athlete should have at least some understanding.
          If we’ve arrived at a place where Tramadol use is so common, as you say, perhaps that place is part of the problem?
          (My rudimentary maths below was that 8 x riders will now have to do the work that x 9 did previously – more ‘pain’ – a 9th extra, i.e. 11%).

          • We haven’t arrived at any new place.
            Since sport *even exists* (call it Ancient Greece or whatever) people have been trying to take whatever could improve their performance, irrespective of health consequences. I named the Classical age because we’ve got some written records about the question.
            That’s why tramadol is so common. Does it improve results? Probably yes. Is it legal? Yes. Will it put your health at risk with no medical justification? Yes. Final result: a lot of guys are do take it.

            The difference in modern sport (which includes a decent number of decades) it that it’s less than ever a personal decision: the team, people you’re accustomed to obey to, people who are supposedly competent and in charge of your health, that is, managament and medical staff, will create a significant pressure on you as an athlete in order to make you take whatever they say. Even more so with a prescription drug. Some doctor is signing something somewhere and not exactly because that specific patient has undergone surgery. I wonder if they even keep any coherence between prescription and riders who are administered the drug (I suppose that laws are different from country to country, too).
            And that’s precisely why the institutions should think twice before allowing these products outside of therapeutical use.

            But truth is that most sport institutions, teams and organisers just *love* the pharmacological aspect of the sport and won’t do anything to further limit it unless the riders and perhaps the public ask for some thing different.
            It’s a great way to disciplinate sport politics (managing what’s in the list and what isn’t); it protects investment (makes the sport more predictable and more corresponding to a solid rate between money and victories); it reduces the negotiating power of talented riders (who, however talented, will need adequate *technical support* to triumph or to compete at the proper level); it brings a lot of money to the sport (for example, through the ambigous world of “supplements” – have a look at how many “sport supplements” sponsors are around, let alone pharma corporations!).

            * * *

            Finally… the global effort an abstract rider undergoes today looks inferior to what they had to some 15, 25, 40 or 70 years ago.
            But the whole concept makes little sense to any person familiar to cycling effort, which is multidimensional and complex, as you suggest.
            Several people from track and field world used to tell me that the 400m sprint (the so-called “death lap”) was way more “dreaful” and “painful” than the 10km or the 100m. What does that exactly mean? We could explain that, but it shows you that (elementary) maths doesn’t always tell the whole effort story.
            In cycling effort is even more impredictable and diverse. In that sense, it’s easy to imagine a scenario in which a race with smaller teams *might* become less demanding from a merely physical POV than one with bigger teams – for most riders, at least (yeah, because in cycling a certain kind of scenario might be more demanding for some riders and less for others). But probably we’ll soon get to a situation of similar effort… the maximum available.
            The workload of athletes is pretty much decently understood, nowadays, it just doesn’t fit within banal formulas (a lot of sport scientists following the spiritual guide of Ferrari, who preferred to speak of “sport art”… :-P).

    • Take the rule to reduce team sizes at the Tour also.
      Does that meant that the effort required of the eight riders increases by 11%?
      A completely reactionary and arbitrary rule that can result in more pain.
      The whole thing is reactionary tinkering, but unfortunately its the riders’ bodies that ultimately bear the effects.

      • I’m not convinced by the rule, either, but I’m pretty sure that it doesn’t mean that the effort required to the eight riders increases by 11% (whatever that means).

      • “Reactionary tinkering” is my phrase of the day. And much argument here seems like “reactionary argument” too.

        The “if it hurts then you must stop” crowd are very depressing people.

        • Although it must be said that the afore-mentioned crowd – if it exists at all; I haven’t seen a glimpse or it – are not half as depressing as people who…who…who fail to grasp that it is never too late to run away and join the circus.

          • Who has said “if it hurts you must stop”?
            I’m asking why cycling has a history of pain-reduction / masking drugs in the peloton, it can’t be purely for performance gain?

  16. Great write-up, but I wonder if they ‘fixed’ the cortisone test? If I recall correctly the reason Lotto-Jumbo left was because the cortisol testing wasn’t fully reliable, causing them to miss George Bennett at the 2015 Giro and Theo Bos at the 2013 Vuelta. (Although the Theo Bos case apparantly found a real issue with his medication)

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