Improper use of OTC medication by recreational and age group athletes

September 5, 2016

 So we all think that the use of performance enhancing drugs is just confined to elite athletes? This is just not true, and high percentages of athletes are commonly using over the counter (OTC) medication to improve their performance. According to Waterbrook, (2009), “30-50% of participants in Ironman races and marathons are reported to take NSAIDs.” This is a staggering number considering the risks, and it is apparent that many age group athletes either are not aware or ignore the fact that OTC’s are drugs, perhaps because they are not provided by prescription?

So what is my opinion on this? Well, as a professional triathlete in the 1990’s, I was tested numerous times, so made myself fully familiar with all the requirements of being a clean athlete. My realization was that any and all medications were better avoided as the risks both physically and to my reputation did not warrant any of the potential or perceived benefits. My performances certainly brought a high level of speculation which was not apparent to me at the time, but was revealed to me after I “retired” by the former chairman of the South African Triathlon Association (affiliated to the ITU). I always wondered why I was tested so often. Therefore, my personal experiences have provided me with sufficient knowledge to provide qualified advice on this subject. Again sources referenced here are established athletic journals, recognized sports scientists and qualified medical professionals. I have avoided anecdotal evidence. Furthermore, the following may not be a complete list of easily obtainable medications but the principle is reasonably comprehensively applicable.

I can anticipate that many age group athletes consider that because they are not elite athletes that the legislation around the use of drugs in sport does not really apply to them. It certainly does! I competed and won the Masters World Championship in Road Cycling in 2012 and although I was not tested the second place competitor was. Can you imagine how I would have felt if I had used an OTC that was banned and been tested positive!

Apart from the fact that the use of medication may be illegal, it also can be extremely dangerous. Furthermore, I personally have strong opinions that it is completely unethical. There are medications that are not on the banned substance list but I still advise complete avoidance based on this opinion.
As indicated above the most common OTC used are Non-steroidal anti-inflammatories (NSAIDs). These are a class of OTC and prescription medications that include Ibuprofen (Advil and Motrin), Naproxen (Aleve), Aspirin and others (Waterbrook, 2009). Quinn, (2016) states that “endurance athletes have been using ibuprofen and other NSAID’s before and during competition in an attempt to compete at the highest intensity for the longest duration.” It is the before and during competition that bothers me the most. Quinn also came to the conclusion that NSAIDs had no positive effect on sports performance and may, in fact, cause a serious health risk in some endurance athletes.

So what are the risks of using NSAID’s? According to Waterbrook, (2009) the most dangerous is bleeding from the gastrointestinal tract. This is usually associated with chronic use, but can also be seen acutely. Prolonged use can also lead to kidney damage. NSAIDs have further been shown to increase gastrointestinal permeability and contribute to the development of hyponatremia when taken by endurance athletes during long races.

The connection between hyponatremia and NSAID use was a completely new revelation to me. Hyponatremia is a condition caused by overhydration and is a recent phenomenon which has been researched by Professor Tim Noakes. Noakes earned Doctor of Medicine and Doctor of Science degrees from the University of Cape Town in South Africa. He has written more than 50 studies on the subject, but his pièce de résistance is Waterlogged: The Serious Problem of Overhydration in Endurance Sports. I will discuss the subject of hyponatremia in the future but at this time I want to point out the unintended consequences of NSAID use and the potential massive risk to your health. Noakes relates that people have died and that he has counted a dozen deaths in endurance events caused by exercise-associated hyponatremia.

There have been some articles suggesting that Tylenol can improve athletic performance. Tylenol is supposed to be gentler on the stomach. Some studies have indicated acetaminophen in normal (i.e. not hot) conditions, can result in a significant improvement in time-trial performance (Hutchinson, 2013). The suggested reasons are that performance improves due to masking of pain, and that acetaminophen improves heat tolerance. However, Burfoot (2010) states that researchers hasten to point out that there are dangers to ACT use. If the analgesic effect masks some sort of tissue or bone damage, it could "put you at greater risk of injury." They also note: "We do not condone or recommend the chronic use of analgesics for the enhancement of athletic performance." Although Tylenol is thought to be relatively safe, toxicity due to acetaminophen is the most common cause of acute liver failure in the United States (Aschwanden, 2009). I would certainly be very concerned about the effects of taking acetaminophen under the stress experienced during an Ironman.

The other commonly used drug is salbutamol used for asthma. Now I will hear people say but this is allowed! Yes it is, but on condition that you have submitted a therapeutic use exemptions (TUE) application to your association which has been approved. If you are a high performing age group athlete this is a warning as salbutamol can in some countries be legally obtained as an OTC. There is an aspect to this which concerns me as some individuals are “diagnosed” too easily as having asthma as an excuse to use asthma medication as a performance enhancer. Also a study by C Goubaulta et al (2000) concluded that “inhaled salbutamol, even in a high dose, did not have a significant effect on endurance performance in non-asthmatic athletes, although the bronchodilating effect of the drug at the beginning of exercise may have improved respiratory adaptation.“ So if you don’t have asthma it doesn’t help your performance!

Another common OTC that is used is pseudo-ephedrine (Sudafed) which is a common cold remedy and is indicated as a banned stimulant according to the World Anti-doping Code. Just prior to a national championship I came down with a head cold so took a few aspirin and Sudafed to clear the symptoms but stopped taking medication 48 hours before the race. As mentioned, I was paranoid about being completely ethical so presented a letter to the officials stating the facts knowing the facts but also considering that it is only present in the blood stream for a few hours. Annoyingly, I was instructed to not compete.

A really grey area which I need to discuss relates to the use of thyroid stimulating hormones for cases of hypothyroidism even though these drugs are not OTC’s. I have crossed paths with two high performing athletes who have been diagnosed with this condition. In an article by Tucker (2013) he draws a parallel with asthma, for which athletes can get TUEs to use steroid-containing inhalers to restore “normal” function and compete fairly. His concern is that the situation is subtly different, because the allegation is that it’s the training that causes the condition to begin with. That’s not the case for asthma, which is an existing condition, admittedly worsened by intense exercise, but not a direct consequence of exercise participation and training. I certainly agree with Tucker as I consider any “athletes who require medical assistance that nudges their hormones levels up to restore them to levels typical of a non-training individual are benefitting from an unnatural practice that directly changes hormone levels”. In my opinion, regulating the issue of drugs that can influence hormone levels needs to be implemented. Determining that an athlete genuinely needs to be treated for hypothyroidism is a major hurdle that needs to be overcome by the regulators.

In conclusion as a coach and athlete I am completely against the use of any form of medication before and during racing and training. The fact that OTC’s are easily obtainable does NOT make them safe, in the majority of cases they do not provide any performance benefits, and can potentially mask pain and promote injuries. I also have a major issue from an ethical standpoint on any coach that recommends the use of medication in such instances. Coaches are there to provide advice and guidance on training techniques and programs that can optimize athletic performance, and not to cross the line into medically enhanced performance regimes. Just because we may work with amateur age group athletes does not make it any different to an elite athlete taking performance enhancing drugs illegally. 
I will finish up with a personal anecdote of one of my worst experiences of being tested. It was when I competed and won the British Half Ironman Championships. Unusually for the U.K. the weather was hot and the organizers provided insufficient water at the feeding stations. I finished and was required to be tested (I think it was because the Brits didn’t trust this unknown South African athlete). I was completely dehydrated and couldn’t pass any urine for the sample. The medical team would not put me on a drip even though it was indicated by the doctor, as that would have compromised the test. After over 2 hours and several bottles of water which were promptly vomited back up I managed to pee. The Brits even added insult to injury and waited for the test to be declared clear before paying the prize money.

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