WADA leak gives clues to possible PED TUEs of Simone Biles & Williams Sisters

Iain Kidd examines and explains the recent revelations that some of America’s most famous Olympians may have been competing while using performance enhancing drugs.

Disclaimer: Nothing written in this article should be taken as an accusation that any athlete used any substance in order to illegally enhance their performance. All reported therapeutic use exemptions come from a recent leak of WADA documents from the Fancy Bears group, and have not had their authenticity verified. As such, they should be considered unconfirmed reports.

First, a definition is in order: For the purposes of this series of articles, a performance-enhancing drug (PED) is a substance which is banned by a governing body due to its potential ability, or perceived ability, to enhance performance.

Many substances which are considered performance-enhancing drugs are also used in the course of legitimate medical investigations and treatments. There is no clear, delineating line between a medicine and a performance-enhancing drug. Any medicine which could potentially result in biological or physiological changes that are conducive to increased athletic performance can be considered a PED.

The WADA prohibited list contains many medicines that you, or someone you know, may take. Here is a small sample of common medications which are prohibited for use in competition by WADA:

Many inhalers:

  • Prescribed for the treatment of asthma and other respiratory issues

Insulin:

  • Prescribed to Type-1 and some Type-2 diabetics

Amphetamines:

  • Prescribed for the treatment of attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD)

Opiate based painkillers:

  • Prescribed for acute pain, or certain types of chronic pain

Corticosteroids:

  • Prescribed in injectable form as a treatment for injuries, especially ligament injuries
  • Prescribed in topical form for some skin conditions
  • Prescribed in inhalable form to treat asthma and other respiratory illnesses
  • Prescribed as an oral pill to treat a variety of inflammatory conditions, especially in those who cannot take non-steroidal anti-inflammatory medications (NSAIDs)

These medications are used to restore normal function to a person who may be suffering from a medical condition or injury. Unfortunately, when taken by a healthy person, they can potentially increase their abilities beyond what would normally be possible. For this reason, they are banned except under a few conditions.

A therapeutic use exemption (TUE) exists to allow athletes with medical conditions to compete while taking otherwise banned drugs. The caveat is that the use must be therapeutic. This means the dose must be only what is required to treat the medical condition. Without this exemption, no person with Type-1 diabetes, for instance, could ever compete in the Olympics, as insulin is a banned substance.

Certain substances are only banned above a specific threshold. Many asthma treatments are allowed, with no TUE required, as long as the amount used stays below a specific level. For instance, the asthma medication Salbutamol (Albuterol/Ventolin) may be taken up to a maximum dose of 1600 µg per 24 hours. Athletes requiring more than this to treat their condition must apply for a TUE.

There is no allowed level of most medications. For instance, amphetamines used in the treatment of ADHD are banned at any dose. This means any athlete receiving amphetamines as part of their treatment, even if they only take a miniscule amount of the substance, must apply for a TUE in other to do so.

Most MMA fans are likely aware of TUEs due to their role in allowing several fighters to partake in testosterone replacement therapy (TRT) in the past. Exemptions such as this highlight the difficulty in policing this system. It is very possible, even probable, that some athletes use the TUE system to try to gain a performance advantage over their opposition. WADA tries to prevent this by setting the following four conditions on any TUE application:

1) The athlete’s health would be substantially impaired if treatment was withheld.

2) The treatment is highly unlikely to provide an enhancement to performance, beyond that expected by the treatment returning the athlete to full health.

3) There is no reasonable therapeutic alternative to the prohibited substance/method.

4) The TUE is not required due to prior use of prohibited substances.

Even with these requirements, the system isn’t perfect. I will try to explain the possible performance-enhancing benefits of any prohibited substance an athlete has taken under a TUE. This should not be taken as a suggestion that the athlete in question was abusing their TUE to gain an advantage, simply as knowledge of how an otherwise healthy athlete could gain an advantage if they used the substance in question.

Simone Biles has publicly admitted to taking medication to treat her ADHD since she was a child. The leaked WADA documents support this, showing that she has received therapeutic use exemptions for two ADHD medications at various points in her career: methylphenidate (Ritalin) and dexmethylphenidate (Focalin/Focalin XR).

During this time period, Biles apparently tested positive for metabolites of dex/methylphenidate four times at the 2016 Olympics in Rio. The documents show that she had a valid therapeutic use exemption for the substance at this time, and as a result, no punishment was given.

There are a variety of medications prescribed for ADHD. Typically, these are either pure amphetamine-based medications, such as Adderall or Dexedrine, which contain various amounts of pure amphetamine salts, or methylphenidate-based medications, such as Ritalin or Focalin. There are also other, atypical medications, such as Strattera, Kapvay, and Intuiv that are generally used in cases of ADHD which do not respond to first-line treatments.

Both methylphenidate and amphetamine-based ADHD therapies have been found to have similar effects on focus and mental cognition, however, amphetamine-based therapies have a slightly larger physiological effect on blood pressure. Amphetamines have historically been abused in sports which require significant concentration over a long period of time, such as baseball.

Studies examining the potential performance-enhancing benefits of amphetamines have found that at therapeutic doses, there is likely no effect on maximal effort – an athlete could not perform beyond their usual capacity due to the amphetamine. However, larger doses of amphetamines have been shown to potentially increase maximal effort by 1-5%. Both therapeutic and higher doses have been shown to increase how long a person can perform at or near maximal effort, likely due to reducing the perception of fatigue.

It should be noted that methylphenidate has a different neurochemical mechanism of action to pure amphetamine or methamphetamine, and as a result could be more, or less, effective at enhancing athletic performance. It appears that Simone Biles only ever received a therapeutic use exemption of dex/methylphenidate, not any medication containing pure amphetamine. Both medications work in an extremely similar, but not identical way.

Serena Williams has neither confirmed nor denied the accuracy of the documents listing her therapeutic use exemptions. The substances she allegedly received therapeutic use exemptions for are:

  • methylprednisolone
  • prednisolone
  • prednisone
  • hydromorphone
  • oxycodone

Methylprednisolone, prednisolone and prednisone are all corticosteroids of the glucocorticoid type. They are not anabolic steroids. Corticosteroids do not increase muscle mass like androgenic/anabolic steroids. When people talk about steroids as performance-enhancing drugs, they are almost always referring to anabolic/androgenic steroids, not corticosteroids.

When corticosteroids are taken orally, as was reportedly the case for Serena Williams, they are most often being prescribed to reduce systemic inflammation. This could be anything from a respiratory infection to an autoimmune disorder. Corticosteroids are used in the treatment of literally hundreds of conditions.

It appears that all of Serena Williams’ reported corticosteroid TUEs were for short periods of time. TUEs for glucocorticosteroids are typically given for severe asthma or conditions like inflammatory bowel disease, and are not that uncommon. I am unaware of any significant performance-enhancing benefit of oral glucocorticosteroids outside of helping to mask the effects of an injury.

Hydromorphone and oxycodone are powerful opiate-based painkillers that are typically prescribed for severe pain. Evidently, Serena Williams was only ever granted short-term (around one week) TUEs for oxycodone, but received a hydromorphone TUE which was valid for several months. Serena Williams was struggling with a serious foot injury at the time the documents show she was granted her hydromorphone TUE.

Serena Williams does not appear to have competed while receiving a therapeutic use exemption for either oxycodone or hydromorphone. Oxycodone and hydromorphone would both significantly decrease a person’s perception of pain. They are also likely to increase drowsiness and negatively impact athletic performance. It is unlikely they have any significant performance-enhancing benefit outside of allowing people to compete while injured or in pain.

Venus Williams has neither confirmed nor denied the accuracy of the documents listing her therapeutic use exemptions. The substances she allegedly received therapeutic use exemptions for are:

  • triamcinolone
  • formoterol
  • prednisone (oral and intramuscular)
  • prednisolone

While we covered prednisone above, it is worth looking at how the documents show Venus Williams used it, as one of her therapeutic use exemptions was for a prednisone injection, rather than an oral pill. When injected, prednisone is most often used to treat inflammation at a particular area, and is commonly used for ligament injuries. It appears that Venus Williams received this treatment around the time of the 2013 Australian open, during which she lost in the third round. It would not enhance performance beyond potentially allowing an athlete to compete more effectively while injured.

Triamcinolone is another glucocorticosteroid, which according to the documents, was used in its injectable form by Venus Williams. When injected, triamcinolone is most commonly used to treat injuries in the same manner as prednisone. I am not aware of any mechanism by which it could enhance performance beyond potentially allowing an athlete to compete more effectively while injured.

Formoterol (Foradil) is most commonly used as an inhaler for treating asthma and other respiratory issues. It appears that Venus Williams received a formoterol TUE for roughly one year, from 2010 to 2011. Formoterol is used to keep respiratory conditions under control, and is not used to treat acute attacks like some other inhalers.

Formoterol has been found to increase energy expenditure and fat burning without a corresponding increase in heart rate. Studies have been performed examining formoterol as a potential performance-enhancing substance in both normal and cold climates, but no evidence of any benefit was found.

Part two of this series will examine the therapeutic use exemptions granted to other American athletes, as well as British athletes, including Tour de France and multiple Olympic gold medal winner, Sir Bradley Wiggins.

Iain Kidd examines and explains the recent revelations that some of America’s most famous Olympians may have been competing while using performance enhancing drugs.

Disclaimer: Nothing written in this article should be taken as an accusation that any athlete used any substance in order to illegally enhance their performance. All reported therapeutic use exemptions come from a recent leak of WADA documents from the Fancy Bears group, and have not had their authenticity verified. As such, they should be considered unconfirmed reports.

First, a definition is in order: For the purposes of this series of articles, a performance-enhancing drug (PED) is a substance which is banned by a governing body due to its potential ability, or perceived ability, to enhance performance.

Many substances which are considered performance-enhancing drugs are also used in the course of legitimate medical investigations and treatments. There is no clear, delineating line between a medicine and a performance-enhancing drug. Any medicine which could potentially result in biological or physiological changes that are conducive to increased athletic performance can be considered a PED.

The WADA prohibited list contains many medicines that you, or someone you know, may take. Here is a small sample of common medications which are prohibited for use in competition by WADA:

Many inhalers:

  • Prescribed for the treatment of asthma and other respiratory issues

Insulin:

  • Prescribed to Type-1 and some Type-2 diabetics

Amphetamines:

  • Prescribed for the treatment of attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD)

Opiate based painkillers:

  • Prescribed for acute pain, or certain types of chronic pain

Corticosteroids:

  • Prescribed in injectable form as a treatment for injuries, especially ligament injuries
  • Prescribed in topical form for some skin conditions
  • Prescribed in inhalable form to treat asthma and other respiratory illnesses
  • Prescribed as an oral pill to treat a variety of inflammatory conditions, especially in those who cannot take non-steroidal anti-inflammatory medications (NSAIDs)

These medications are used to restore normal function to a person who may be suffering from a medical condition or injury. Unfortunately, when taken by a healthy person, they can potentially increase their abilities beyond what would normally be possible. For this reason, they are banned except under a few conditions.

A therapeutic use exemption (TUE) exists to allow athletes with medical conditions to compete while taking otherwise banned drugs. The caveat is that the use must be therapeutic. This means the dose must be only what is required to treat the medical condition. Without this exemption, no person with Type-1 diabetes, for instance, could ever compete in the Olympics, as insulin is a banned substance.

Certain substances are only banned above a specific threshold. Many asthma treatments are allowed, with no TUE required, as long as the amount used stays below a specific level. For instance, the asthma medication Salbutamol (Albuterol/Ventolin) may be taken up to a maximum dose of 1600 µg per 24 hours. Athletes requiring more than this to treat their condition must apply for a TUE.

There is no allowed level of most medications. For instance, amphetamines used in the treatment of ADHD are banned at any dose. This means any athlete receiving amphetamines as part of their treatment, even if they only take a miniscule amount of the substance, must apply for a TUE in other to do so.

Most MMA fans are likely aware of TUEs due to their role in allowing several fighters to partake in testosterone replacement therapy (TRT) in the past. Exemptions such as this highlight the difficulty in policing this system. It is very possible, even probable, that some athletes use the TUE system to try to gain a performance advantage over their opposition. WADA tries to prevent this by setting the following four conditions on any TUE application:

1) The athlete’s health would be substantially impaired if treatment was withheld.

2) The treatment is highly unlikely to provide an enhancement to performance, beyond that expected by the treatment returning the athlete to full health.

3) There is no reasonable therapeutic alternative to the prohibited substance/method.

4) The TUE is not required due to prior use of prohibited substances.

Even with these requirements, the system isn’t perfect. I will try to explain the possible performance-enhancing benefits of any prohibited substance an athlete has taken under a TUE. This should not be taken as a suggestion that the athlete in question was abusing their TUE to gain an advantage, simply as knowledge of how an otherwise healthy athlete could gain an advantage if they used the substance in question.

Simone Biles has publicly admitted to taking medication to treat her ADHD since she was a child. The leaked WADA documents support this, showing that she has received therapeutic use exemptions for two ADHD medications at various points in her career: methylphenidate (Ritalin) and dexmethylphenidate (Focalin/Focalin XR).

During this time period, Biles apparently tested positive for metabolites of dex/methylphenidate four times at the 2016 Olympics in Rio. The documents show that she had a valid therapeutic use exemption for the substance at this time, and as a result, no punishment was given.

There are a variety of medications prescribed for ADHD. Typically, these are either pure amphetamine-based medications, such as Adderall or Dexedrine, which contain various amounts of pure amphetamine salts, or methylphenidate-based medications, such as Ritalin or Focalin. There are also other, atypical medications, such as Strattera, Kapvay, and Intuiv that are generally used in cases of ADHD which do not respond to first-line treatments.

Both methylphenidate and amphetamine-based ADHD therapies have been found to have similar effects on focus and mental cognition, however, amphetamine-based therapies have a slightly larger physiological effect on blood pressure. Amphetamines have historically been abused in sports which require significant concentration over a long period of time, such as baseball.

Studies examining the potential performance-enhancing benefits of amphetamines have found that at therapeutic doses, there is likely no effect on maximal effort – an athlete could not perform beyond their usual capacity due to the amphetamine. However, larger doses of amphetamines have been shown to potentially increase maximal effort by 1-5%. Both therapeutic and higher doses have been shown to increase how long a person can perform at or near maximal effort, likely due to reducing the perception of fatigue.

It should be noted that methylphenidate has a different neurochemical mechanism of action to pure amphetamine or methamphetamine, and as a result could be more, or less, effective at enhancing athletic performance. It appears that Simone Biles only ever received a therapeutic use exemption of dex/methylphenidate, not any medication containing pure amphetamine. Both medications work in an extremely similar, but not identical way.

Serena Williams has neither confirmed nor denied the accuracy of the documents listing her therapeutic use exemptions. The substances she allegedly received therapeutic use exemptions for are:

  • methylprednisolone
  • prednisolone
  • prednisone
  • hydromorphone
  • oxycodone

Methylprednisolone, prednisolone and prednisone are all corticosteroids of the glucocorticoid type. They are not anabolic steroids. Corticosteroids do not increase muscle mass like androgenic/anabolic steroids. When people talk about steroids as performance-enhancing drugs, they are almost always referring to anabolic/androgenic steroids, not corticosteroids.

When corticosteroids are taken orally, as was reportedly the case for Serena Williams, they are most often being prescribed to reduce systemic inflammation. This could be anything from a respiratory infection to an autoimmune disorder. Corticosteroids are used in the treatment of literally hundreds of conditions.

It appears that all of Serena Williams’ reported corticosteroid TUEs were for short periods of time. TUEs for glucocorticosteroids are typically given for severe asthma or conditions like inflammatory bowel disease, and are not that uncommon. I am unaware of any significant performance-enhancing benefit of oral glucocorticosteroids outside of helping to mask the effects of an injury.

Hydromorphone and oxycodone are powerful opiate-based painkillers that are typically prescribed for severe pain. Evidently, Serena Williams was only ever granted short-term (around one week) TUEs for oxycodone, but received a hydromorphone TUE which was valid for several months. Serena Williams was struggling with a serious foot injury at the time the documents show she was granted her hydromorphone TUE.

Serena Williams does not appear to have competed while receiving a therapeutic use exemption for either oxycodone or hydromorphone. Oxycodone and hydromorphone would both significantly decrease a person’s perception of pain. They are also likely to increase drowsiness and negatively impact athletic performance. It is unlikely they have any significant performance-enhancing benefit outside of allowing people to compete while injured or in pain.

Venus Williams has neither confirmed nor denied the accuracy of the documents listing her therapeutic use exemptions. The substances she allegedly received therapeutic use exemptions for are:

  • triamcinolone
  • formoterol
  • prednisone (oral and intramuscular)
  • prednisolone

While we covered prednisone above, it is worth looking at how the documents show Venus Williams used it, as one of her therapeutic use exemptions was for a prednisone injection, rather than an oral pill. When injected, prednisone is most often used to treat inflammation at a particular area, and is commonly used for ligament injuries. It appears that Venus Williams received this treatment around the time of the 2013 Australian open, during which she lost in the third round. It would not enhance performance beyond potentially allowing an athlete to compete more effectively while injured.

Triamcinolone is another glucocorticosteroid, which according to the documents, was used in its injectable form by Venus Williams. When injected, triamcinolone is most commonly used to treat injuries in the same manner as prednisone. I am not aware of any mechanism by which it could enhance performance beyond potentially allowing an athlete to compete more effectively while injured.

Formoterol (Foradil) is most commonly used as an inhaler for treating asthma and other respiratory issues. It appears that Venus Williams received a formoterol TUE for roughly one year, from 2010 to 2011. Formoterol is used to keep respiratory conditions under control, and is not used to treat acute attacks like some other inhalers.

Formoterol has been found to increase energy expenditure and fat burning without a corresponding increase in heart rate. Studies have been performed examining formoterol as a potential performance-enhancing substance in both normal and cold climates, but no evidence of any benefit was found.

Part two of this series will examine the therapeutic use exemptions granted to other American athletes, as well as British athletes, including Tour de France and multiple Olympic gold medal winner, Sir Bradley Wiggins.