Therapeutic Use Exemptions – Legalised Doping or Medical Necessity?

by Dr Ian Boardley

“Until recently, Sir Bradley Wiggins was one of the darlings of the British public. Already the first Briton to win the Tour de France, Wiggins apparently secured his legacy by winning another gold medal at the Rio Olympics and becoming the country’s most bemedalled Olympian. However, Wiggins’ reputation has recently been questioned by some, after the Russian hacker group Fancy Bears released confidential information that related to athletes’ sanctioned use of prohibited substances. ”

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Authorized use of prohibited substances in sport is permitted in specific circumstances when it is required for the treatment of a legitimate medical condition. Such sanctioned use of banned substances is governed through the Therapeutic Use Exception (TUE) system. TUEs can be granted by an Anti-Doping Organization following a review process that involves an athlete obtaining evidence from a medical professional that demonstrates the following three criteria have been met:

  1. The athlete would experience significant health problems without taking the prohibited substance
  2. The therapeutic use of the substance would not produce significant enhancement of performance
  3. There is no reasonable therapeutic alternative to the use of the otherwise prohibited substance

Once submitted, the TUE application is evaluated by three physicians with relevant specialisms who collectively make the decision whether to approve it.

So why has there been such a furore surrounding Wiggins’ case in particular? First, there is the specific substance he was injected with - a powerful long-acting corticosteroid called triamcinolone. Although this medication is suitable for the treatment of severe allergic reactions to pollen, it is also associated with a number of potential performance enhancing effects such as reducing body fat, speeding recovery and suppressing feelings of fatigue. Then, there is also the timing of Wiggins’ use of triamcinolone. The three times he obtained a TUE for its use immediately preceded the three most challenging races of his career (2011 and 2012 Tour de France, 2013 Giro d’Italia). This has led some to question whether his use of triamcinolone was purely for therapeutic purposes.

Ultimately, there is insufficient information available for those outside of Bradley Wiggin’s “inner circle” to judge whether his TUEs were obtained purely for medical reasons or if possible performance benefits were also a motivating factor. However, Wiggin’s case – and the Fancy Bears leak more generally – have made public an issue that has been discussed by those working in the anti-doping arena for some time, the existence of a grey area between the often black-and-white distinction made between athletes who compete “clean” and those who “dope”.

The existence of the TUE system creates a situation whereby doping substances can be used legally but not necessarily ethically. This is a particular issue if those involved, such as athletes, managers and team doctors, lack the objectivity to recognise when they may be crossing ethical boundaries when applying for TUEs. This means it is essential that any system sanctioning the use of prohibited substances for medical reasons is sufficiently robust that it does not rely on those applying for TUEs making the distinction between ethical and unethical use of prohibited substances. Whether the current TUE system is suitably robust is a major issue for anti-doping, and one that is being debated extensively at present.