Performance Enhancing Drugs In Ultramarathons

In 2002, I ran the Grand Slam of Ultrarunning and chronicled my entire journey from Western States to Wasatch online for UltraRunning Magazine. In doing so, I wrote that I was administered an IV after finishing Western States and was given supplemental oxygen after completing Leadville. The online ultra community at the time consisted of the ULTRA List (a listserv that enabled ultrarunners to easily communicate ultra-related information). Upon hearing that I had used these recovery techniques, practices that if used during any single event would be grounds for disqualification, some of the ULTRA List subscribers believed that my Grand Slam should therefore be declared invalid since I still hadn’t finished all four races.

A few months later, a longtime friend and fellow ultrarunner visited me in Moab, Utah. Our conversation turned to injuries and recovery. He said he (and others he knew) frequently used dimethyl sulfoxide (DMSO), a pharmaceutical topical solvent that eases pain and reduces inflammation, to heal or mask a muscle injury so he could keep training and racing. Post-race IVs and oxygen seemed innocuous enough, but this was my first conversation about using chemicals to enhance recovery. I soon discovered that it wasn’t uncommon for ultrarunners to use prescription painkillers, marijuana, testosterone, insulin, and thyroid medications: drugs that not only improved recovery, but could boost performance as well. Some runners had bona fide medical issues that required the use of these substances, but was this the case for everyone? And if it wasn’t, did it matter?

These days, my coaching athletes ask my opinion on what they should and should not do and what they can or cannot use. The answers to their questions aren’t as simple as you’d think and here’s why.

What are Performance-Enhancing Drugs?

If it weren’t for drugs, many of us wouldn’t be here today. They lower blood pressure and cholesterol, ease pain, control asthma, allergies, and diabetes, fight cancer and help control depression. When a substance is used solely as a way to get ahead in the world of sport, they become performance-enhancing drugs or PEDs. ProCon.org, a site that explores the pros and cons of controversial issues, shares a better definition, “Performance-Enhancing Drugs [are] various substances, chemical agents, or procedures designed to provide an advantage in athletic performance. Performance-enhancing drugs affect the body in different ways, such as enlarging muscles or increasing the blood’s oxygen-carrying capacity. Despite these apparent benefits, the use of such drugs is considered both competitively unethical and medically dangerous. Most performance-enhancing drugs are outlawed by organizations that govern major amateur and professional sports.”

Examples of PEDs run the gamut from steroids (testosterone) to hormones (erythropoietin or EPO, human growth hormone or HGH, insulin), diuretics (glycerol) to stimulants (large amounts of caffeine, cocaine, epinephrine) and narcotics (morphine, oxycodone) to cannabinoids (marijuana). Though some of these drugs are legal to obtain and possess, they become banned substances under certain governing bodies and during certain competitions. Athletes caught using said products lose their titles, prizes, participation rights, and sometimes their sponsorships. The World Anti-Doping Agency (WADA), an international independent agency whose mission is to lead a collaborative worldwide movement for doping-free sport, maintains a running list of these prohibited substances and methods. WADA’s prohibited list isn’t utilized by every event. In fact, the numbers of races that don’t have any particular PED rules or regulations vastly outnumber the competitions that do follow a strict WADA protocol that entails drug testing and penalties if caught.

Many performance-enhancing substances naturally occur in our own bodies. When supplemented by needle, cream, or pill, they enhance the properties of that innate material. However, if taken too often or at improper doses, the user can experience stroke, heart attack, liver damage, increased blood pressure and cholesterol, diabetes, acne, heart deformations, insomnia and, in some cases, death. According to clinically based journals, like PharmacyTimes.com, and anecdotal evidence, some of the most common PEDs abused in endurance sports are:

1. EPO – A hormone that produces red blood cells. This improves oxygen delivery to the muscles thus improving endurance performance.
2. Steroids – Testosterone and its derivatives promote muscle growth, strength, bone mass, and possibly increased red blood cell count.
3. Insulin – Improves stamina by enabling the user to load the muscles with glycogen (fuel) before and between events.
4. HGH – There is limited evidence that HGH improves athletic performance. However, it’s often used in tandem with other drugs because it increases lean body mass, decreases body fat, and builds connective tissue (especially in older athletes).
5. ECA or EC stack – The combination of ephedrine, caffeine, and aspirin (which can be omitted based on tolerance) brings about weight loss without a loss in muscle mass and also acts as a stimulant.
6. Thyroid medications – Used to treat fatigue-causing hypothyroidism. However, for athletes training hard this could provide, according to Science-Based Pharmacy, a “recovery-enhancement or fatigue-deferring boost.”

Therapeutic Need Versus Performance Enhancement

Ultrarunners are only human. We struggle with ailments including arthritis, back, muscle and nerve pain, diabetes, asthma, hormone imbalances, depression, and glaucoma. We are required to take medications to control these issues. However, many of these drugs can be construed as PEDs. It might surprise many ultrarunners to learn that a puff from an inhaler or joint and many of the pills and potions prescribed by your doctor can be considered performance enhancing depending on the elixir and its dose. Let’s be realistic, though. We’re not going to cease necessary prescription-drug use so we can participate in an event. Even WADA accounts for this beneficial drug use by issuing therapeutic use exemptions (TUEs), when needed. This approves and authorizes an athlete competing in major amateur and professional sporting events to use prohibited substances that are necessary to maintain their wellbeing.

Who is Using PEDs?

The list for positive tests in track and field and road running is long and growing. In 2013, The New York Times published an article that indicated, “Far more athletes are doping than might be imagined.” The article shared that during 2010 less than 2% of the drug tests performed by WADA came back positive. In 2011, more than 2,000 track and field athletes were asked to complete an anonymous survey on doping. Twenty-nine percent of the athletes in the 2011 IAAF World Championships in Athletics and 45% in the 2011 Pan-Arab Games admitted they used PEDs. This is a jaw-dropping discrepancy.

Where does this leave the sport of ultrarunning? Comrades and Two Oceans Marathons, two large ultramarathons in South Africa, have both had winners test positive. On June 16, 2015, I asked the ultrarunning community to participate in a cursory one-question, yes-or-no answer anonymous survey: Have you ever used a performance-enhancing drug (PED) while training for or participating in an organized ultramarathon (a running/hiking event/race of 50K in length or longer)? For the purposes of this survey PEDs include: testosterone, any steroid derivatives, blood doping, ephedrine, prescription painkillers or narcotics, insulin, erythropoietin (EPO), human growth hormone (HGH), marijuana, or (meth)amphetamine. In the end, 705 ultrarunners responded of which 9% have used PEDs.

A few ultramarathoners who have been disqualified for PED use include:

Objective Versus Subjective

The distances ultrarunners cover, terrain crossed, conditions encountered, and our own unique physiology can blur the line between fact and opinion. For example, what really are the best training philosophies, race strategies, and nutrition regimes for a 100-mile event? We don’t really know the answers as success has been forged with a multitude of approaches.

WADA, on the other hand, has created an extensive and definitive list of the drugs and procedures athletes shouldn’t be using in or out of competition. But where do we, as ultrarunners, draw the line? Are listening to music and using trekking poles performance enhancing? How about using a pacer or crew? What about cortisone and platelet-rich plasma (PRP) injections, weekly massage and chiropractic work, living at altitude, living at sea level, utilizing an Alter-G anti-gravity treadmill or altitude tent, having access to good healthy food, taking an IV after an event, and using supplemental oxygen? As long as people differ in opinion there will always be a debate as to what the limit is on performance-enhancing advantages.

Drugs in Ultras

Ultrarunning has certainly experienced its share of growing pains. Today, events are flourishing, prize purses have grown and athlete-sponsorship opportunities have increased. PED use has become a hot topic of discussion due to these added incentives. Are we ready to police for PEDs in U.S. ultra events? Do we have the resources? Are we ready to add this component to a quickly growing sport when we don’t know how the majority of ultrarunners and race directors perceive the PED question?

Drug testing is rare in ultras except at world championships and races like Ultra-Trail du Mont-Blanc and at International Skyrunning Federation events. The International Association of Ultrarunners (IAU) implements doping controls at the 24-Hour, 50k Road, 100k Road, and Trail World Championships. Stateside testing takes place as well, but less frequently. Richard Bolt, an executive committee member for the USA Track and Field Mountain/Ultra/Trail (MUT) Council explains, “The Pikes Peak Ascent in Colorado conducted testing in 2010 and 2014 when it was the World Long Distance Mountain Running Challenge. Out-of-competition testing occurs on U.S. soil for U.S. athletes who have performed well at World Mountain Running Association (WMRA) and IAU Championships.”

Why, then, are national championships and other prestigious U.S. events not testing when it helps to safeguard prize money, creates a level playing field, and ensures the validity of course records? Bolt continues, “We’re trying to get testing at all USATF MUT Championships but the challenge is funding such a program. USA Track & Field hasn’t provided the budget and race directors are reluctant to add another cost to their event. Most drug testing I’ve seen entails three to four testers and their devices to administer tests for immediate results. Often other samples are sent to approved offsite labs. Pre- and post-competition personnel and equipment are needed for two to three days. At this year’s IAU Trail Championships in Annecy, France, two samples were taken. One sample was tested on-site with immediate results. The second sample was used for a different test and sent off-site. This entire process adds up to a hefty price tag.”

Nancy Hobbs, chairperson of the USATF MUT Council, elaborates on why testing costs are high, “It depends on factors like lead time, the choice of drug analysis (blood, urine, or both), and the event’s location relative to the testing labs. You must consider the sample collection process and travel time of both the test organizers and the athletes’ samples. Costs vary from country to country. For example, at the Mountain Running World Championships, typically the winner and a random assortment of runners get tested. The price rises slightly as more runners are tested. At various WMRA events, I’ve seen anywhere between one to six athletes evaluated depending on the requirements based on the race’s contractual agreement.”

Those that face the greatest impact of a strict anti-drug policy are race directors and the athletes. It’ll ultimately be their voice that dictates the discussion of whether drug testing at more ultras should take place or not.

Nick Coury, the race director of the Desert Solstice Invitational Track Meet in Phoenix, Arizona, works with the US Anti-Doping Agency (USADA), a fully compliant signatory to WADA, to ensure that records set at his race meet USATF and IAU drug-testing protocol. “Today, drug tests aren’t required to ratify American or age-group records. Outright world records are the only records that require testing,” says Coury. “For example, in 2011, we tested Jay Aldous’s 100-mile age group record only to find it wasn’t necessary. However, in 2013, we had to test both Zach Bitter’s 12-hour world record and Pam Smith’s 100-mile track world record. They passed and that brings positive attention to our event, but it also cost us $2,500 for the two tests.”

Ellie Greenwood, winner of Western States 100 Mile Endurance Run and the IAU 100k World Championships (twice), has been tested often since her first win at the 2010 World Championships. “I was tested at the finish line of that race and because I won I was put on the WADA Whereabouts register for about 18 months,” explains Greenwood. “This wasn’t optional. The Whereabouts process has an online system where you must provide an overnight address for 365 days of the year plus a one-hour daily time slot where you can be found. Testers can show up at that time and you must provide urine and/or blood if they do. They can also show up at any other time. If you are not there then there are no consequences, but you must submit to a test if they find you.”“I’ve also been tested before Courmayeur Champex Chamonix 100k (CCC) in 2012, at all four Comrades I’ve raced, as well as at the finish line of Two Oceans in 2013. I came in seventh at Two Oceans, but was moved to sixth after the woman’s winner failed the doping control for steroids.” (See Natalia Volgina in the chart above.)

Throughout this strict and frequent testing process, Greenwood still feels strongly about drugs in our sport. “I think it makes the sport cleaner but it is not a 100% fool-proof system. We can’t have individual races just making up their own doping procedures, but maybe it is time that more ultras were under a single governing body,” says Greenwood. “More runners are trying to make a living from our sport and so the temptation to use PEDs has increased. Maybe they feel it’s acceptable to do so because most races don’t state anything in their rules about PEDs. The testing system needs to keep evolving to keep up with those who are determined to find a way around it.”

Where Does this Leave Us?

Perhaps Dick Pound, a former WADA chairman, summed it up best for both the current state of ultrarunning and the other activities WADA regulates, “There is no general appetite to undertake the effort and expense of a successful effort to deliver doping-free sport. There’s this psychological aspect about it: nobody wants to catch anybody. There’s no incentive. Countries are embarrassed if their nationals are caught. And sports are embarrassed if someone from their sport is caught.”

Dr. AJ Gregg, a Certified Strength and Conditioning Specialist with a Doctorate in Chiropractic and Masters of Science in Human Nutrition and Functional Medicine, treats U.S. and foreign athletes who must adhere to WADA’s World Anti-Doping Code and are subject to both in- and out-of-competition drug testing as well as elite and non-elite trail and ultrarunners. It was interesting to hear Gregg’s (who is not an ultrarunner) perspective when I asked him if he thought ultrarunners used PEDs. “Finishing a 100-mile event is a rite of passage for an ultrarunner. Similar to a walkabout or vision quest,” says Gregg. “It’s simply the runner versus the course. Suffering is a huge component of the ordeal and I’d imagine they’d do what’s necessary to finish.”

With 8.5% of the American population diagnosed with asthma, more than 9% dealing with diabetes, 12% developing thyroid problems, 25% of men over 30 with low testosterone, 40% battling cancer, and 70% currently using prescription drugs, we can be fairly certain that PED use is occurring in every ultramarathon in the U.S. due to medical necessity. However, PED use alone isn’t the problem; dishonest intent, taking drugs when they aren’t needed, is the key issue at hand. Using PEDs becomes this Armstrong/Salazar debacle when taken for the sole purpose of getting ahead and when used in an event that strictly prohibits it. Until the day comes, if it ever does, when drug testing becomes the norm for prestigious ultra events in the U.S., we must simply continue to do what we’ve done up to now: trust our fellow ultrarunners.

Call for Comments (from Bryon and Meghan)

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• Given the lack of a governing body and a more stringent anti-doping testing regime, what do you think ultrarunning as a community needs to do to keep ourselves ‘clean?’ How to we establish and keep that trust to which Ian refers?
• What did you learn from this article that you didn’t previously know about PEDs or their use?