Things do not go as planned…
The tension is high. Fans anxiously await. The empty dome sits ready for one of the biggest boxing matches of the year. Milena is ready to step foot in the ring in less than 19 hours. She is the fan favorite in the 60 kg division. Her weigh-in is finally over, hitting exactly 60 kg. “Thank God! I can finally eat!” she thinks to herself as she chugs back a bottle of water. She can’t wait to get back to the Athletes’ village, where her trainer has food prepared for her.
She starts eating a carefully prepared pre-fight, midnight snack. Suddenly, she notices tingling in her throat. A drip of sweat glides down the side of her forehead. Milena feels how her throat starts to swell and that she can’t breathe properly. She tries to stay calm, but panic slowly creeps up in her. Something is very wrong.
An emergency may occur anytime
Surely the chef at the athletes’ village should know that some athletes have peanut allergies? She knows this feeling. This is an allergic reaction! Milena, with no time to think, fumbles her EpiPen out of her backpack, pulls it out of its case, and presses it firmly against her thigh with a trembling fist.
An EpiPen is an auto-injection device that delivers a measured dose of epinephrine. People prone to anaphylaxis, a serious allergic reaction that may cause death, carry it on them in case they experience such an event. An EpiPen can save your life. But epinephrine, a stimulant, is prohibited in sports.
The coaches run towards her as she calls for help. They immediately rush her to the polyclinic to be treated and monitored. She feels the swelling subsiding and can breathe easier. Her panic diminishes, but she slowly realizes what just happened: she injected herself with a prohibited substance—on the eve of the fight of her life…
I took a prohibited substance just before my event – why does it matter?
The World Anti-Doping Agency’s Prohibited List (“List”) contains substances and methods that are banned in sport. In the early days of anti-doping programs in sport, athletes were only tested during competitions. As sport and (anti-)doping evolved, out-of-competition testing began.
Hence, the substances on the List are divided into two categories:
1) Prohibited at all times
- These substances are banned both during and out-of-competition. Your anti-doping agency can test for them at any time, anywhere.
2) Prohibited in-competition
- These substances are banned only while you compete. The in-competition time frames vary depending on your competition and/or sport. Generally, you may be tested from 11:59 pm on the eve of your competition until you finish competing. Be sure to check with your anti-doping organization or sport federation for the specific times for the in-competition period for your event, competition or Games.
Milena’s “in-competition” period starts at 11:59 pm on the day before her fight. Her bout is set for tomorrow evening at 2000h, but she has injected her EpiPen past midnight. She is an international level athlete and has received anti-doping education in the past. They had warned her that many medications are prohibited and require permission before using them. If she recalls correctly, epinephrine is banned, but she can’t remember if it is prohibited at all times or just during in-competition.
Where to check what is prohibited
Milena’s allergic reaction subsides further as she is monitored at the polyclinic. She goes to check a website called Global DRO on her iPhone. This website will tell you if a certain substance or medication is prohibited at all times or just during competition periods.
Epinephrine is, in fact, banned in-competition only. But Milena’s manager has already confirmed with the anti-doping agency that her in-competition period has started already. This means that she used a banned medication in-competition. She discusses with the on-call doctor at the polyclinic: as soon as possible, she needs to get a retroactive Therapeutic Use Exemption (TUE). Her team doctor arrives from the training site and joins them.
What are “retroactive” TUEs?
As an athlete, you may suffer from a disease or sustain an injury, whether related to your sport or not. In our blog “A Right to Fair Sport – TUEs,” Dr. Grimm explains the Therapeutic Use Exemption (TUE) system that is meant to allow athletes to use a prohibited substance to treat a genuine disease or injury when and if needed. She also explains the process on how to apply for a TUE. Whenever possible, you should request your TUE in advance. But there are some situations when you can only apply for a TUE after you have taken the prohibited substance. These are called retroactive TUEs.
When can you apply for retroactive TUEs?
You may be allowed to apply for a TUE retroactively for a prohibited substance if any of the below applies to you. This is defined in WADA’s International Standard for TUEs or “ISTUE”. Below, we have given you the most common examples for each situation where applications for retroactive TUEs are permissible, however, it is critical to check with your anti-doping organization.
Emergency or urgent treatment of a medical condition was necessary
- An example of this would be Milena’s case. Life-threatening allergic reactions such as bee stings and nut allergies require immediate medical attention. Your well-being and health come first and must never be compromised. Urgent treatment should never be delayed because of TUE worries.
Due to exceptional circumstances, there was insufficient time or opportunity for an Athlete to apply for a TUE
- Susan is a young promising swimmer. She suddenly makes the National Team as a backup. Her team is ready to go to the Worlds in a week. She is on treatment for her attention deficit disorder since her childhood. Four days later, she participates in an education session about TUEs. She has no time to go to her specialist and obtain the medical documents to apply.
The anti-doping rules required or permitted an Athlete to apply for a retroactive TUE
- As an athlete, the first thing you need to do is find out if you actually need a TUE and to whom you need to apply. This depends on your competition level, country, and sport. Some anti-doping organisations may not require lower-level athletes to apply for a TUE in advance, which means before using the medication. These athletes may only need to apply if they have been tested and the medication is found in their urine or blood sample (i.e. you can apply after you have tested positive).
There are other exceptional situations that may occur. You need to contact either your national Anti-Doping organization or your international sport federation and check carefully with them. Remember, all of the above situations will let you apply for retroactive TUEs but it is not always guaranteed that your TUE will be granted.
All of the above are currently valid reasons that allow you to apply for retroactive TUEs. You can learn more about TUEs and their updates on the WADA e-learning platform, ADeL. The criteria will slightly change with the new version of the ISTUE in 2021. We will update the criteria as it becomes available.
So, what now for Milena?
Milena can apply retroactively, describing the emergency treatment with her team doctor, who submits a TUE application for the use of epinephrine injection. It contains a description of Milena’s symptoms when she started eating, the observations of her coaching team, and the records of the polyclinic doctor. Her team doctor has kept the note of Milena’s peanut allergy diagnosis on file.
The biggest problem with retroactive TUEs is that often, the documentation of what happened is not ideal. For example, an emergency was not observed, or there was no time for documenting it. Another example is a doctor who is not familiar with treating athletes and the anti-doping rules. Still, the application has to meet the official criteria for the TUE to be granted. It is very important to keep all medical documentation with you. We will describe how you can best prepare for this challenge in a future blog.
Don’t add more stress to your competition
The prompt medical treatment, as prescribed by her doctor, not only saved her life but luckily allowed for a quick recovery. She was fortunate that she knew about the anti-doping rules so that was able to get retroactive approval of her treatment before her fight. The last thing she needed at that time was further stress and anxiety.
**based on a true story.