Athlete Guide to the 2013 Prohibited List
The World Anti-Doping Agency provides annual updates to the Prohibited List. This guide is designed to help U.S. athletes understand how the Prohibited List applies to them with specific attention paid to medications available on the U.S. market. This guide is not an exhaustive discussion of the 2011 Prohibited List but instead should be read in conjunction with the Prohibited List (download the complete version from www.USADA.org). The use of a Prohibited substance in sport requires an approved Therapeutic Use Exemption (TUE). This document should be read in conjunction with the Prohibited List available here
Substances and Methods Prohibited at all times (both in- and out-of competition).
The first section of the Prohibited List discusses substances and methods that are prohibited at all times, both in- and out-of-competition. Any athlete, including elite (registered testing pool) athletes or non-national level (e.g. Masters, juniors) can be tested for these substances at any time.
S0. Non-Approved Substances
This “open” section addresses the issue of the abuse of pharmacological substances for the purpose of performance enhancement that are not included in other sections of the Prohibited List. They include substances that are not approved by any governmental regulatory health authority for human therapeutic use (i.e. drugs under pre-clinical or clinical development or discontinued, designer drugs, or veterinary drugs). These substances will be prohibited at all times (in- and out-of-competition).
S1. Anabolic Agents
Anabolic Agents are prohibited. This includes the use of testosterone creams (such as Androgel) or shots, or the use of any other anabolic substance. The list of anabolic agents is extensive, but even if an anabolic agent is not specifically listed it is still prohibited if it has “a similar chemical structure or similar biological effect(s)”.Advisory:
- Clenbuterol is sometimes used to treat asthma, and it is sometimes used in other countries to “bulk up” livestock. There is no threshold limit for clenbuterol meaning the detection of any amount of clenbuterol in the sample is a positive test.
- There have been many instances of products marketed as dietary supplements that contain one or more anabolic agents. For a few examples, see the High Risk List on Supplement411.org. The High Risk List is not an exhaustive list of supplements that will make you test positive! It is merely a list of examples of products that pose an increased risk of causing a positive doping test. Use of any supplement is at your own risk.
S2. Peptide Hormones, Growth Factors and related Substances
This class of substances includes Erythropoietin (EPO), human chorionic gonadotropin (HCG), luteinizing hormone (in males), growth hormone, IGF-1, corticotrophins, and a number of other growth factors.
- There are products marketed as dietary supplements that claim to either contain, or to boost the release of EPO, IGF-1, and growth hormone. Peptide hormones and their releasing factors, AND other substances with similar chemical structure or biological effect(s) are prohibited. If such products actually do what they claim to do then they are prohibited1.
- Human chorionic gonadotrophin (HCG) is prohibited in sport at all times, and is an Food and Drug Administration (FDA) approved prescription medication for the treatment of female infertility. It is not approved as a weight loss drug. The FDA warns consumers to avoid "homeopathic" HCG weight-loss products because they are illegal. They are sold in the form of oral drops, pellets and sprays and can be found online and in some retail stores.
- The definition of growth factors includes any “growth factor affecting muscle, tendon, or ligament protein synthesis/degradation, vascularization, energy utilization, regenerative capacity or fiber type switching.
- Even though Platelet Rich Plasma (PRP) contains some growth factors, WADA has clarified that PRP is not prohibited.
S3. Beta-2 Agonists
All oral (taken by mouth and swallowed) beta-2 agonists are prohibited.
Inhaled beta-2 agonists are prohibited and require a Therapeutic Use Exemption (TUE) except for formoterol (dosages less than 54 micrograms/24 hours), salmeterol (when taken according to manufacturer’s instructions), and albuterol (dosages under 1600 micrograms/24 hours). Search www.GlobalDRO.com to determine if the inhaler that you are using contains a substance that requires a TUE for use in sport.
- The dosage of albuterol or formoterol that may be used in sport without a TUE may translate into a wide range of “puffs”. You should examine your inhaler closely to determine the dosage. If you need to take more than the non-prohibited dosage you must apply for a TUE.
- Albuterol and formoterol are “threshold substances” which means they may be used in sport without a TUE as long as they are used under a certain threshold. However, if you also need to use a substance that falls into the category of diuretics and masking agents you need to have a TUE for albuterol or formoterol even though you have a TUE for the diuretic or masking agent.
- Use of oral beta-2 agonists is prohibited even if you have a TUE for the same inhaled beta-2 agonist. If your doctor prescribes an oral beta-2 agonist you should submit an application for a TUE.
- Some inhalers have more than one active ingredient. Make sure you check all the ingredients on www.GlobalDRO.com.
- The presence of albuterol in urine in excess of 1000ng/mL is presumed NOT to be an intended therapeutic use, and may be considered as an adverse analytical finding.
S4. Hormone Antagonists and Modulators
In short, the following are prohibited: aromatase inhibitors, selective estrogen receptor modulators (SERMS) such as tamoxifen, other estrogenic substances, and agents modifying myostatin function(s), and insulin. Please consult the Prohibited List for examples of substances in each of the above classes.
S5. Diuretics and Other Masking Agent
Masking agents are prohibited, including diuretics and plasma expanders.
- WADA has clarified that local administration of Felypressin for dental anesthesia is not prohibited.
- The use of any quantity of a threshold substance (i.e. albuterol, formoterol, cathine, ephedrine, methylephedrine and pseudoephedrine) in conjunction with a diuretic or other masking agent requires a TUE for the threshold substance AND the diuretic. This means two TUEs are needed. This is the one case where an otherwise permitted substance (like albuterol used under its threshold) requires a TUE.
M1. Enhancement of Oxygen Transfer
The title of this category is new in 2013. It has been changed to “manipulation of blood and blood components” to make clear that it encompasses all kind of manipulation of the blood. Blood doping, the use of red blood cells of any origin, or otherwise artificially enhancing the uptake or delivery of oxygen is prohibited. Any type of IV manipulation of the blood or blood components by physical or chemical means is prohibited.
- Supplemental oxygen (e.g. breathing an oxygen rich air mixture temporarily, such as on the side-lines) is not prohibited.
- Use of hyperbaric or hypobaric tents is not prohibited.
M2. Chemical and Physical Manipulation
Tampering, or attempting to tamper in order to affect the validity of samples collected during the doping control process is prohibited. Intravenous infusions or any intravenous injection of more than 50mL per 6 hour period are prohibited except for those legitimately received in the course of hospital admissions or clinical investigations.
- Even if the substance to be delivered by intravenous infusion is not prohibited (such as saline), the method remains prohibited outside of the scope of allowable use (hospital admissions/clinical investigations).
- IV infusions and IV injections exceeding 50mL/6 hours are prohibited and require a TUE unless they are received in a hospital or in the course of clinical investigations (make sure to read WADAs position on IV infusions found here: http://www.wada-ama.org/Documents/Science_Medicine/Medical_info_to_support_TUECs/WADA_Medical_info_IV_infusions_3.0_EN.pdf ). In an emergency, you should always receive appropriate medical care. If the emergency physicians need to insert an intravenous line to save your life or provide emergency medication then just make sure you obtain all the clinical documents that help document the diagnosis and decision to start the IV. Once the emergency is over you can communicate with USADA to determine if a TUE is required for the emergency.
- Physicians frequently raise concerns about the emergency use of IV infusions in cases of severe GI distress (such as during travel) and dehydration. WADA has clarified “the use of IV fluid replacement following exercise to correct mild rehydration is not clinically indicated nor substantiated by the medical literature."
- The prohibition of “the sequential withdrawal, manipulation, and reintroduction of any quantity of whole blood” is not intended to prevent plasmapheresis (a specialized form of blood donation) or similar processes.
- Those undergoing hemodialysis, as part of the treatment of chronic kidney disease, will require a TUE for such procedures (and the substances that are often used to treat such disorders).
M3. Gene Doping
The transfer of polymers of nucleic acids or nucleic acid analogues, or the use of normal or genetically modified cells is prohibited.
Substances and Methods Prohibited In-Competition
This section focuses on substances that are prohibited only in-competition. These substances are not tested for out-of-competition. It is very important to be aware of the definition of “in-competition.” Each International Federation may have a different definition of “in-competition” and it may vary by event. For some events, “in-competition” may be defined as “12 hours before the start of the competition” and different rules may apply to multi-day events (for example, the Olympic Games). It is very important for athletes to understand the definition of “in-competition” for the sporting events in which they compete. Athletes must ensure that all substances prohibited in-competition have completely cleared from their body before competition. If this is not possible, or if the chronic use of one or more of these medications is needed, the athlete should apply for a Therapeutic Use Exemption (TUE).
All stimulants and their optical isomers (d, l) are prohibited except for imidazole derivatives for topical use, and those stimulants on the 2012 Monitoring Program (buproprion, caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradrol, and synephrine).
- Athletes diagnosed with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) who are taking stimulants and competing should obtain a TUE for their medication. Athletes who are not competing do not need to obtain a TUE in order to use these medications.
- Athletes diagnosed with narcolepsy, and prescribed medications that contain modafinil or armodafinil, for example, should obtain a TUE if they need to take these medications just prior to or during competition.
- Pseudoephedrine is an ingredient in several over-the-counter cold and flu medications. WADA has issued an advisory to athletes that they should discontinue taking medications containing pseudoephedrine AT LEAST 24 hours prior to the time defined as “in-competition.” However, in some cases this may not be enough time for the substance to clear from the body, especially if the product is a slow-release product. USADA recommends avoiding pseudoephedrine-containing cold and flu products for several days in advance of competition.
- Nicotine and caffeine are not prohibited but they are part of the WADA monitoring program.
Certain narcotics are prohibited in-competition: buprenorphine, dextromoramide, diamorphine (heroin), fentanyl and its derivatives, hydromorphone, methadone, morphine, oxycodone, oxymorphone, pentazocine, pethidine (meperidine). Use of these narcotics in-competition requires an approved TUE.Advisory:
- Opium, the latex extract of the poppy plant, contains morphine and therefore it is also prohibited.
Natural or synthetic tetrahydrocannabinol (THC) and THC-like cannabinoids (e.g. hashish, marijuana, HU-210) are prohibited.
- Athletes should be aware that cannabinoids may be retained in fat tissue following chronic use and may be detected weeks after use. There have been situations where sudden weight loss has caused cannabinoid metabolites stored in fat to be released in detectable levels. USADA strongly advises athletes not to use cannabinoids at any time.
- Although recreational marijuana use was recently legalized by Colorado and Washington voters in constitutional amendments, marijuana use remains prohibited in sport in accordance with the 2013 WADA Prohibited List.
The systemic use of glucocorticosteroids is prohibited in-competition. This includes oral (like a Medrol Dose pack) or a systemic injection.
The systemic use of glucocorticosteroids is prohibited in-competition. This includes oral (like a Medrol Dose pack) or a systemic injection (IV or intramuscular), or by rectal routes.
- Athletes who are prescribed oral glucocorticosteroids (Medrol Dose Pack for instance) may take these medications out-of-competition without a TUE as long as the prohibited substance has cleared their system prior to the time defined as “in-competition”. If athletes need to use glucocorticosteroids by oral, intramuscular, or rectal routes shortly before, or during competition, they must obtain a TUE.
- Injection of glucocorticosteroids around tendons, into joints, and epidural (into the spine) is not prohibited, but injection into a muscle is prohibited.
- Inhalation of glucocorticosteroids (e.g. for asthma) is not prohibited.
- Topical use of glucocorticosteroids (anti-rash cream, hemorrhoidal creams etc.) is not prohibited. But be aware that some suppositories contain glucocorticosteroids. This would be considered a rectal route of delivery and is prohibited in-competition.
Substances Prohibited in Particular Sports
Some sports have additional rules about the use of substances such as alcohol or beta-blockers. If you participate in any of the following sports please consult the WADA Prohibited List or Global Drug Reference Online (GlobalDRO.com) before using alcohol or beta-blockers:
Shooting (ISSF, IPC)
USADA References and Resources
This guide was intended to introduce athletes, and others involved in sport, to the Prohibited List and to provide practical guidance on how the Prohibited List may affect them. This guide is not intended to be exhaustive, and should be read in conjunction with the Prohibited List. Ultimately, the athlete is solely responsible for the substances in his or her body. Further information on the topics contained in this guide can be obtained by consulting the references and resources below.
The 2013 Prohibited List can be downloaded from http://www.usada.org/prohibited-list
Athletes can call Athlete Express to reach the Drug Reference Line) on (800) 233-0393 for questions about medications, substances, methods, and other related topics.
Global DRO (www.GlobalDRO.com) is a searchable online database of medications available in the United States, Canada, and the United Kingdom that details the status of medications.
You may contact USADA’s Drug Reference Department on 719-785-2045 for questions on Therapeutic Use Exemptions.
USADA does not provide medical advice or recommendations. Athletes should make all decisions on treatment with their physician in conjunction with the 2013 Prohibited List.
1 Many products marketed as dietary supplements make false, misleading, or deceptive claims of what they actually do. Thus such products may not actually boost EPO of IGF-1 or growth hormone at all, but if they do then they are prohibited. USADA considers such products to be high risk for causing positive anti-doping tests or health problems. The use of any dietary supplement is at your own risk.