WADA’s Prohibited Substance List: A Psychiatric Perspective

1. WADA’s Prohibited Substance List: A Psychiatric Perspective 15th FINA World Sports Medicine Congress Indianapolis, October 12th, 2004 Presenter – Saul I Marks, M.D. Toronto, Ontario, Canada

2. Goals • Consistency in Doping Control is paramount • Is there consistency with the “Psychotropic Medications”? • Consistency with Therapeutic Use Exemption • Continuing review of “Psychotropic Medications” is needed

3. Drug Classification • Psycho-stimulants • The sedative-hypnotics and alcohol • The anti-depressants • Analgesics, anti-psychotics and the mood stabilizers

4. Attention-Deficit Disorders • Attention-deficit/hyperactivity disorders (ADHD), inattentive type, hyperactive-impulsive type, combined type • 3-5% of children and adolescents • 2-3 times more prevalent in males then females • Most common reason for children to be referred to mental health services DSM - IV

5. Etiology • Many variable studies • Involvement of both the dopaminergic and catechoaminergic systems • Mesolimbic system involved in hyperactivity, prefrontal cortex involved in symptoms of inattention and impulsivity. Beh and Brain Res, 130 (2002) 65-71

6. Treatment • First-line treatment are Methylphenidate and Dextroamphetamine • Side effects– sleeplessness, appetite suppression, weight loss and emotional lability • Side effects controlled by decreasing the dose • Prohibited Substance • Therapeutic Use Exemption? Consistency and guidelines Int J Sports Med 2003; 24: 535-540

7. Guidelines • Proper documentation • History of ADHD and meet criteria for the disorder • Symptom control on stimulant therapy • Documented evidence of response by rating scale • Treatment reviewed regularly, yearly? • Relapse off of treatment

8. Sedative-Hypnotics and Alcohol • Very few studies, older studies, although alcohol is banned in particular sports and not in others (banned in gymnastics, not in diving) • Limited studies with benzodiazepines and newer agents • Many questions remain regarding performance and these agents with different half-lives, and the newer agents zolpidem and zopiclone • One study showed longer acting benzo caused morning drowsiness and decreased psychomotor performance vs. zopiclone

9. Further Research? • Could short-acting sedative-hypnotics, and/or newer agents aid sleep night before performance and enhance performance? • Could longer-acting benzodiazepine help performance in low dose or in tolerant person? • Consistency regarding alcohol as a prohibited substance Cl Jour Sport Med, 10; 123-128, 2000

10. Antidepressant Classes • Monoamine oxidase inhibitors • Tricyclic antidepressants • Selective serotonin reuptake inhibitors • Serotonin-norepinephrine reuptake inhibitor – BUPROPION • Alpha-2 antagonist - mirtazapine • Serotonin antagonist/reuptake inhibitor - nefazadone

11. Bupropion • Increases levels of both dopamine and norepinephrine, similar to stimulants? • Second-line agent in treatment of ADHD along with Venlofaxine • Does Bupropion warrant further investigation as a potential ergogenic agent? • Consistency

12. Analgesics, anti-psychotics and the mood stabilizers • Codeine is a permitted substance, morphine is prohibited • Codeine is metabolized to morphine in the liver - ? Consistency? In prohibited substance list? • Anti-psychotics need to be classed alone (tendency to be forgotten as a separate class of drugs?) • Mood Stabilizer – Topiramate – weight loss agent of abuse in the literature, out of competition use?

13. Summary • TUE in Attention Deficit Disorder • Sedative-Hypnotics and Alcohol deserve further evaluation • Bupropion deserves further evaluation

14. Questions?

15. QUESTIONS? • /