The opioid epidemic in the United States and around the world is not a secret, but how much do people really know about the abuse of prescription drugs in sport? Are they aware of how often seemingly innocent prescriptions for oxycodone or tramadol can turn into full-blown addictions? That the addiction can lead to an overdose and death? That it can happen to anyone, even athletes? Especially athletes?
At USADA, we believe that medical advice should come from physicians, but it is within our purview to draw attention to health and safety issues that impact athletes. As such, USADA has publicly provided education and guidance on substances and methods that are on the World Anti-Doping Agency (WADA) Prohibited List, while also pushing for other substances to be added to the List because of associated health risks and performance-enhancing capabilities.
One such drug is the narcotic painkiller tramadol, a still-legal substance in sport that is both powerful and dangerous. USADA, alongside numerous other organizations in the world of sport, believe that the time is now for WADA to finally move the drug from its Monitoring Program (where it has been since 2012) to the Prohibited List, alongside 12 other narcotics that are already banned in-competition.
While USADA and other consulted stakeholders provided substantial evidence about the health risks and abuse of tramadol in sport after WADA requested comment on its inclusion in 2015, WADA has not yet added the drug, which is being abused in at least one sport. According to the WADA Monitoring Program, 71 to 82 percent of the tramadol use between 2012 and 2015 in globally monitored sports occurred in cycling.
Without doubt, tramadol raises legitimate questions about how it should be regulated in sport, as it has both clinical utility and potential for abuse. The debate becomes particularly complex when a drug is associated so closely with a single sport.
However, the enormity of the drug’s threat becomes more apparent when some athletes talk about their experiences with the powerful painkiller.
An Athlete’s Reality
Ian Mullins, an elite mountain bike racer, points out that tramadol is the go-to painkiller for many athletes, especially cyclists, despite its reputation of abuse. Speaking from experience, he explains that athletes feel perceptible pain relief by taking tramadol – a potent painkiller – before, during, and after intense workouts or competitions – all without risking a positive test. Unlike other narcotics, such as oxycodone and morphine, athletes know they can use tramadol whenever the pain hits and still remain compliant with anti-doping rules.
Which is, in large part, how Mullins got addicted to the drug.
He started taking tramadol when his doctor prescribed it to him as pain relief from chronic pancreatitis, but soon realized that he could both train and race better while taking the drug.
“Using tramadol can feel as good as getting a blood transfusion for athletes,” says Mullins. “You can pop a pill 18 hours into a 24-hour endurance race and it’s an immediate boost that helps you power through the end.”
Fortified by recollections of his doctor saying that tramadol-dependency wasn’t something he’d encountered, Mullins started getting tramadol through other routes when his prescription ran out, wanting the pain relief and believing that he wouldn’t get addicted. But before long, his days were consumed by watching the clock, counting down the minutes between doses.
His addiction was obvious – and disturbing – to both himself and those around him. His dependency destroyed a relationship, and it made him wonder how anyone could simultaneously be an addict and an elite athlete who cares about their body.
Trying to break the addiction, he would avoid taking the drug, only to be overcome by the debilitating symptoms of withdrawal, from nausea to cold sweats. This cycle of need and regret was interspersed with a number of overdoses that left Mullins disoriented, bleeding, and desperate for rehabilitation.
“Getting on and off drugs is hell,” Mullins explains. “Psychologically, I knew I was dealing with addiction, but it took me years of physical struggle to break that addiction.”
This left him questioning how something so powerful and so addictive could be allowed in sport. He saw major benefits on the bike thanks to tramadol’s performance-enhancing properties, while also being crushed by it’s addictive nature and side effects, making it a seemingly obvious candidate for the WADA Prohibited List.
“I don’t want any other athletes to go through what I’ve experienced because they think it’s safe to use tramadol just because it’s not banned in sport,” Mullins notes. “My biggest mistake, other than taking tramadol in the first place, was not asking for help to get off it. There isn’t just one way to overcome addiction, but help is there if you ask, and it can save your life.”
Mullins has witnessed enough fellow cyclists experiencing the highs and lows of tramadol use to know that he wasn’t the only one going through the battle against opioid abuse. Knowing this, he contacted USADA and others to share his story in hopes of spreading awareness about the issue plaguing his sport and fellow cyclists.
The Big Picture
It’s not hard to see why athletes might get addicted to tramadol and other pain medications when they are constantly pushing their bodies to the limits. But as USADA’s Science Director Matthew Fedoruk points out, “We often hear from athletes and others that tramadol is being abused in sport. Our job is to ensure that athletes can compete clean and win, and like other narcotics on the WADA Prohibited List, it’s our belief that tramadol abuse threatens athletes’ health and their right to a level playing field.”
To this point, a study by Loraschi et al. (2014) showed that cyclists identified tramadol as a doping agent, meaning that riders clearly understand that tramadol can be used to enhance performance. According to eyewitness reports, tramadol is even handed out freely with water bottles during cycling races to combat late-stage pain.
On the subject of painkiller use in cycling, elite cyclist Taylor Phinney is quoted in Cycling Tips saying, “You have to ask why are you taking a painkiller? You are doing that to mask effects that riding a bike is going to have on your body…essentially, you are taking a painkiller to enhance your performance. But the whole reason we get into sport in the first place is to test our bodies, to test our limits. If you are taking something that is going to boost your performance, that is not exactly being true to yourself, not exactly being true to your sport.”
The 2015 Cycling Independent Reform Commission Report provides further evidence and echoes rider concerns that tramadol has been widely used in the peloton because of its non-banned status and potent PED qualities.
More Evidence Against Tramadol
In addition to performance-enhancing benefits, research suggests that tramadol can have serious side effects, including the potential for decreased alertness, seizures, and addiction. In terms of addiction, a Washington Post-Kaiser Family Foundation survey found that “one-third of Americans who have taken prescription opioids for at least two months say they became addicted to, or physically dependent on, the powerful painkillers.”
Just deemed a Schedule IV controlled substance in 2014, the U.S. Drug Enforcement Administration (DEA) cited that the addictive qualities of tramadol would lead it to be “diverted from legitimate sources, used without medical supervision, and consequently become a safety concern to individuals and the community.” The DEA additionally cites that symptoms of tramadol abuse are similar to other opiates and can include serotonin syndrome, seizures, and stopped breathing. Because of its toxic mechanisms, tramadol use does come with risk of overdose, and the effects range from significant neurologic toxicity, such as coma, to cardiovascular toxicity like tachycardia. Tramadol can also have adverse interactions with other products. For example, the DEA explains that tramadol’s interaction with alcohol can be fatal and that deaths associated with tramadol have been well documented in medical texts.
Dr. Fedoruk also notes that, like many medications, the pharmacological effects and metabolism of tramadol varies between individuals, even when people use identical doses. If overdose does occur, it’s also important to note that medications like Naloxone (Narcan), often used in emergency situations to reverse an opioid overdose, are less effective in treating a Tramadol overdose and reportedly reverses just 30 percent of tramadol’s effects.
Anecdotal accounts also indicate that tramadol use could be at play in pro peloton crashes. For example, Phinney was quoted in CyclingTips saying, “You see so many late-race stupid crashes that I almost wouldn’t be surprised if some or most of those crashes are caused by people taking these hard-hitting painkillers at the end of races.” This point is substantiated by the fact that the tramadol product insert in the U.S. warns, “While taking [Ultram] DO NOT: Drive or operate heavy machinery, until you know how [Ultram] affects you. [Ultram] can make you sleepy, dizzy, or lightheaded.”
In further support of this theme is a Johns Hopkins study referenced in the Wall Street Journal. From analyzing emergency room visits across sub-Saharan Africa, Dr. Ibrahima Amadou discovered that 80 percent of traffic accidents involved a driver on tramadol.
Based on tramadol’s serious health effects, potential for abuse, the many other narcotics on the Prohibited List, and the fact that there are safer non-opioid analgesic alternatives, USADA continues to urge WADA to add tramadol to the Prohibited List. Prohibiting the use of tramadol in sport will both protect athletes and help ensure a level playing field.
Fighting Opioid Addiction
At this point, tramadol abuse appears to be a threat to all athletes, but particularly those in cycling. As such, USADA encourages all athletes to be informed, make healthy decisions, and reach out to us if they need assistance or information.
Outside of USADA, here are some other relevant resources:
- Behavioral Health Treatment Services Locator
Find alcohol, drug, or mental health treatment facilities and programs around the country at findtreatment.samhsa.gov
- Opioid Treatment Program Directory
Find treatment programs in your state that treat addiction and dependence on opioids, such as heroin or prescription pain relievers, at dpt2.samhsa.gov/treatment/
- Suicide Prevention Lifeline
Website: www.suicidepreventionlifeline.org(link is external)
24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. Your call is routed to the nearest crisis center in the national network of more than 150 crisis centers.
- SAMHSA’s National Helpline
Also known as, the Treatment Referral Routing Service, this Helpline provides 24-hour free and confidential treatment referral and information about mental and/or substance use disorders, prevention, and recovery in English and Spanish.
Cycling Tips, UCI Lobbying WADA to ban Tramadol
Wall Street Journal, The Painkiller that Cycling Wants to Ban
Wall Street Journal, Tramadol: The Opioid Crisis for the Rest of the World
Regulations.gov, Schedules of Controlled Substances: Tramadol; Schedule IV
Washington Post, Post-Kaiser survey of long-term prescription opioid painkiller users
The American of Emergency Medicine, Tramadol-induced apnea
Anaesthesia, Tramadol – the MarmiteTM drug