CyclistDoes cycling have a problem with over-the-counter medication? Part 1Nearly all of us or even all of us have taken painkillers to enable performance. But what about enhancing performance? A recent study suggests its more common than you might think. In a new three-part series, Cyclist takes a deep-dive into the physiological and moral repercussions of visiting the chemistIf we say the words doping cyclist, it no doubt brings to mind the image of some or other disgraced former champion of the sport there are plenty to choose from, after all.What it probably doesnt make you think of is an everyday rider taking over-the-counter medication to ride that bit quicker, that bit longer, that bit ahead of their riding mates. And yet performance-enhancing drugs are by no means the preserve of elite riders. Its not all about EPO, blood bags and steroids. Its time for you to look into your own medicine cabinet and see which way your moral compass is swingingIn search of performance gainsIn 2023, a study appeared on the open platform Sports Medicine-Open revealing that 10% of participants surveyed from more than 200 sports admitted to using over-the-counter (OTC) medication for performance enhancement. The study, entitled Recreational Athletes Use of Performance-Enhancing Substances: Results from the First European Randomised Response Technique Survey, was led by Ask Vest Christiansen, associate professor at the Department of Public Health and Sport Science at Aarhus University in Denmark.We had around 7,000 respondents of whom around 45% had taken OTC medication for reasons other than performance enhancement, like nullifying pain, says Christiansen. Around 10% of respondents also admitted to taking OTC medication to improve performance.Thats about 700 respondents taking drugs such as salbutamol not to ease inflammation of the lungs, but to enlarge the airways in search of more speed. Christiansen says they didnt differentiate between what was deemed by the World Anti-Doping Agency (WADA) to be legal or illegal OTC medication, as that wasnt the driver of the study; it was more about recreational athletes attitudes and moral norms.The wide array of sports covered were divided into four groups. The first was what we termed CGS sports, which are sports measured in centimetres, grammes and seconds, Christiansen said. That includes swimming, cycling, running We then had artistic sports like dance and gymnastics; combat sports like judo and karate; and games, so football, rugby, tennis and so on.Christiansen and his team hypothesised that OTC medication use for performance gains would be highest in CGS sports because the impact is more direct than with finer-skill sports such as football. That marries with the view of Mouvement Pour Un Cyclisme Credible (Movement for Credible Cycling, or MPCC), which has just released its credibility figures across all sports for the period 1st January 2024 to 30th June 2024. Track and field a CGS sport tops the charts with 90 doping, fraud or corruption cases with weightlifting second on 53 and powerlifting third on 34. Cycling was seventh on 11.As it transpired, however, the study found the use of OTC medication to be much more prevalent in games than CGS sports. Does this suggest that us amateur cyclists are all moral and ethical paragons of virtue even if only compared to others? Not quite.The obvious reason for the results is that when talking about recreational athletes, there are many people who ride or jog without ever competing, says Christiansen. They just exercise for health purposes. So, while they might fall into the CGS category, they never compete and so never think about taking OTC drugs. Thats a very different community to riders wholl go out each week on a group effort or race a gran fondo. The number in our study who [regularly] have a race number pinned to their top is relatively small.Its different for games, as its hard to play games without counting the goals, for instance. Most people who play football are in a club structure or in a league structure, even if its just five-a-side, which means the outcome is given more emphasis or importance than if you were just commuting to work by bike.The suggestion here is that if Christiansen had to redirect his focus solely to competitive amateur cyclists, that 10% figure would balloon. While dealing in generalities is a dangerous game, its fair to say that cycling attracts type-A personalities, who are competitive, driven, single-minded and ambitious. Theyre achievement-oriented and impatient to improve. Cyclings data-heavy leanings suits such a personality type, as you can easily monitor heart rate, power output, heart-rate variability and much more besides to track improvements, with the results much more tangible than, say, the accuracy of a Cruyff turn in football or an outswinger in cricket.This ambition, of course, often tips over into cheating, and there are numerous doping cases in the amateur ranks over the years. Take the 2022 case of 58-year-old Italian Luigino DAmbrosio, who was suspended after testing positive for the banned OTC medicine pseudoephedrine at a mountain bike race, or a 2017 survey that showed one in 20 amateur cyclists (adding up to 70 in total) admitted to doping. Related Posts Cycling books: Riding with the Rocketmen by James Witts Doping in cycling: Everything you need to know Ketones for cycling: What are they, do they work and are they banned? Dave Brailsford: To my knowledge nobody has a TUE Michael Barry: I used Tramadol at Sky Enabling vs enhancingTrail running race-organiser UTMB has banned painkillers within 24 hours of and during their races.Patrick McDermott/Getty ImagesLeaving aside the complicated ethics surrounding the issue for now, there are potential physiological and health issues surrounding the use of OTC medications in endurance sport and for an idea of scale, a 2009 study that showed 30-50% of participants in Ironman races and marathons were reported to take NSAIDs (non-steroidal anti-inflammatory drugs), the most well-known of which is ibuprofen.In truth, this probably doesnt come as much of a surprise to most including me, given that I struggled through LEtape du Tour 2022 thanks to a degree of determination, a modicum of training and several painkillers to cool my hot feet.I suffer from sciatica and often take 400mg ibuprofen before a ride, says Jacek Kapela, a Polish rider whos based in Warsaw but used to work in England. His son, Marek, competes for French team Morbihan Adris Gwendal Oliveux and harbours ambitions of graduating to the WorldTour. Sometimes I might take a painkiller called Ketonal if its really bad. I also have friends who, like me, are in their 50s and take painkillers before most rides. Its not about performance enhancement; its just about getting through the ride.This raises the question of the difference between performance enabling and performance enhancing, something that comes up time and time again when discussing OTC medication, WADA and whats deemed legal and illegal. Some have suggested ibuprofen should be banned, and those calls tend to be loudest from the medical community, who say when taken too regularly and over long periods, the side-effects of ibuprofen can range from gastrointestinal ulcers and bleeds to kidney disease and even heart attacks.Theyve actually been banned by the organisers of the UTMB, says Laura Lewis, director of science at the United States Anti-Doping Agency (USADA), referring to the Ultra-Trail du Mont Blanc World Series organisers banning the use of painkillers within 24 hours of, and during all of, their trail-running races.According toDr Patrick Basset,the medical director of Dokever, the company that manages the medical teams at all UTMB events, the regulations have been put in place to protect athletes from the dangers of self-medicating. The most frequent type of self-medication seen is to treat two types of symptoms: osteoarticular pain and digestive problems, he explains on the UTMB website. As a consequence, the main medicines concerned are non-steroidal anti-inflammatory (NSAID), anti-diarrhoea or anti-vomiting medicines.In Lewiss eyes, ibuprofen shouldnt be banned because to be moved onto WADAs prohibited list, it needs to meet two of the following three criteria: its performance-enhancing; its dangerous to the athletes health; and its contrary to the spirit of the sport.Something like ibuprofen might be harmful but typically only in very high doses so its not really dangerous to an athletes health, says Lewis. Theres no evidence that its performance-enhancing, either. Id say its not against the spirt of the sport, too.Thats different to something like pseudoephedrine, found in many cold and flu medicines. Thats a stimulant that could enhance your performance. Taking a medical product to enhance your performance is against the spirit of the sport, which is why this OTC is on the list.Or more specifically, its on the in-competition prohibited list but is allowed out of competition. Lewis advises checking out globaldro.com if you want to check on the sporting legality of any drugs youre taking. You can input the drug and itll say if its allowed or not, and how you may go about getting a TUE (therapeutic exemption certificate) if needed.The danger of addictionAustralian Michael Roeger suffered internal bleeding caused by anti-inflammatories in Beijing 2008.China Photos via GettyWhat about ibuprofen addiction is that a real danger? It is a painkiller, after all. Lewis says the risk of addiction to ibuprofen isnt particularly high. Not in the same way as something like tramadol, which is an opioid and can lead to addiction, says Lewis. Its more like an addiction in that the athlete is scared to feel the pain theyve endured before. They want to prevent that awful feeling.Athletes, whether keen amateurs or elites, often live with pain on a daily basis. But we all have times where pain can become unbearable. That was certainly the case for Australian para-athlete Michael Roeger, who in May 2022 was rushed to hospital with a gastrointestinal bleed.As an athlete you train in Paralympic cycles every four years, so from Beijing I did everything I could to get to London 2012, he wrote at the time. And when I got there, I nearly died. I was racing the heats in the 800 metres when I had a gastrointestinal bleed. The night before the race I was bleeding internally.It was the hardest thing Ive been through. I was spewing up what looked like coffee grinds, but was dried blood, just before I had to go to the cool room to race I was in hospital in London for four days, had to have a blood transfusion, then flew back to Australia to get some more treatment The main cause of the bleed was anti-inflammatories. I had a few little niggles and stuff, and they just rip up your stomach.Paracetamol is another popular OTC medicine that cyclists will use to kill pain. Again, where is the line drawn between enabling and enhancing?A 2013 study, conducted by Dr Lex Mauger of Kent University, concluded that paracetemol delivered an empirical nudge in performance due to 11 recreationally active subjects time-trialling further with paracetamol than without, not simply due to its painkilling characteristics but because it lowers body temperature and so improves performance in the heat.Maugers findings corroborated a 2009 study from the University of Bedfordshire that showed a group of cyclists averaged 26min 15sec for a ten-mile time-trial when loaded with paracetamol compared to 26min 45sec without. Youd have to spend a fair pennyto make 30 seconds difference through bike or components improvements.The payback, though? A study led by Dr Kenneth Simpson of Edinburgh University and the Scottish Liver Transplantation Unit in 2011 analysed 663 patients admitted to Edinburgh Royal Infirmary for liver damage resulting from paracetamol and warned of the danger of staggered overdoses.These cases are rare but do highlight not only the dangers of excessive OTC medication but also the sometimes blurred lines of when an OTC is deemed legal or illegal. Which brings us onto tramadol.The torment of tramadolFormer US Postal and Team Sky rider Michael Barry admitted to taking tramadol during his career.Jalani Morgan / CyclistTramadol is a powerful painkiller that has stimulated controversy in the elite ranks for years, as while it does neutralise pain, it also dampens decision-making, resulting, its detractors have claimed, in a number of high-speed crashes, especially near the end of races thanks to it being used in go-faster finishing bottles. Michael Barry, formerly of US Postal Service and Team Sky, was quoted as saying he could push himself harder when taking tramadol as it masked the pain in his legs. Tramadol made me feel euphoric, but its also hard to focus. It kills the pain in your legs, and you can push really hard, he said.The MPCC first requested a ban on the drug in 2013, and in 2019 the UCI banned it in competition. Finally, as of 1st January 2024, WADA placed tramadol on its prohibited list in competition.Why the wait? When it came to tramadol, there were murmurs of its use and they grew louder, says Lewis. It was then put on whats called the monitoring programme, where the labs will start testing samples and reporting the results just so that WADA can get an idea of is popularity. However, with tramadol, the UCI took it upon themselves to actually ban it earlier than WADA did because they realised that there was a big problem.WADAs updated prohibited list comes into force on 1st January each year, with stakeholders athletes, coaches, and so on given the list the October prior. When it came to tramadol, because of its prevalence in many sports, including cycling and rugby, stakeholders were given a year to prepare, Lewis says.WADAs reticence stemmed from having little performance-enhancement evidence to work with, meaning tramadol didnt fulfil two of the three criteria. That changed after a study by Mauger. He recruited 27 highly trained cyclists whod follow the same cycling pattern: a 30-minute non-exhaustive fixed-intensity effort at high intensity followed by a competitive self-paced 25-mile time-trial. They endured this after a placebo or 100mg soluble tramadol. The results? Tramadol eked out an average 1.3% improvement in performance.We selected a relatively low dose of 100mg for this study to maximise tolerance in this tramadol-nave cohort, but this means the 1.3% improvement in performance observed here is potentially the minimum ergogenic effect that could be observed in races, says Mauger.Go large with tramadol and youd expect an even greater boost, which could lead to danger as, according to Maugers paper, three of the participants expressed and displayed adverse effects in the tramadol condition after the TT completion. For one participant these effects were mild (nausea, mild dizziness), whereas for two these were more pronounced (drowsiness or vomiting).Maugers study showed irrefutable evidence that tramadol enhanced performance, and tramadol was duly banned. That means, in theory, a safer peloton. Or it would. On 12 June, the MPCC sent a letter to WADA to highlight the emergence in the peloton of a new medication, tapentadol (also known as Nucynta), read the MPCCs press release. Much more powerful than tramadol, this opioid has analgesic effects similar to morphine and can therefore push back the pain threshold.Theres a bit of a concern about the possibility of athletes using tapentadol as a replacement drug for tramadol, and WADA have put it on the monitoring programme to reflect this, says Mauger. Ive actually put a proposal into WADA to look at this in a similar way to what we did with tramadol, although I cant say much more about that for the moment.Will the research suggest it boosts performance beyond killing the pain? Does it enable or does it enhance? Or will it sit in the middle like salbutamol, which, says globaldro.com, is permitted by inhalation up to a maximum of 1,600mg over 24 hours in divided doses not to exceed 600mg over eight hours starting from any dose, and prohibited above that threshold?Only time will tell.Stay tuned for part two, where well investigate the moral dilemma and discuss gateway potential. Related Posts Cycling books: Riding with the Rocketmen by James Witts Doping in cycling: Everything you need to know Ketones for cycling: What are they, do they work and are they banned? Dave Brailsford: To my knowledge nobody has a TUE Michael Barry: I used Tramadol at Sky The post Does cycling have a problem with over-the-counter medication? Part 1 appeared first on Cyclist.