Same class of substance, two vastly different sanctions

Much as the World Anti-Doping Agency (WADA) has tried to bring uniform anti-doping rules and uniform application of those rules, differing interpretations often lead to contrasting sanctions. These sanctions through the years have differed from country to country and, as we will soon be able to observe, within a country itself.

Hearing panels in India generally tend to take a sympathetic view of the offence when doping cases are brought before them, especially when the substance belongs to the cannabinoids group or the corticosteroids one.  Unless the case is one of steroid abuse, the panels, at least in India, give plenty of room for the athletes to seek a lenient punishment. Perhaps this is a world-wide phenomenon. But in India, quite often the lack of education programme to familiarize athletes with anti-doping measures, prohibited substances, TUE etc plus the background of the athletes, in several cases those from villages with little understanding of English or awareness about anti-doping rules, contribute towards the eventual sanctions.

Two cases that came out of the National Games in Kerala in February, 2015 deserve mention here. Both were disposed of last December.

In both instances the substances involved belonged to the glucocorticosteroids group. One involving a male athlete from Tamil Nadu ended up in a four-year sanction and the other involving a female wrestler from UP in a one-year suspension.

Corticosteroids are steroid hormones produced in the human body. Glucocorticoids such as cortisol are anti-inflammatory drugs. In sports corticosteroids used to be a restricted drug that required advance notice and permission some years ago. Over a period of time the rules changed. It was a permitted drug through certain routes (periarticular, meaning into a joint, for example) but prohibited through some other routes.

Now there is a simple stipulation in the WADA prohibited list. “All glucocorticoids are prohibited when administered by oral, intravenous, intramuscular or rectal routes.” This will mean an injection into a joint is permitted though it is not specified as it used to be in the past.
Corticosteroids are grouped in the 'specified'category of the Prohibited List, thus enabling a reduction in sanctions if the athlete is able to prove certain conditions.

Corticosteroids, we know, are anti-inflammatory drugs and are used to manage painful conditions. They are also supposed to give a euphoric sensation that could probably explain their misuse in sports. But can that be all?

Do corticosteroids enhance performance?

Some studies have also claimed that they also delay fatigue and thereby enhance performance but this is yet to be conclusively proved. In fact there are scientists who want this class of drugs removed from the prohibited list. This is a debate for the scientists and doctors to pursue and we should leave them the task.

The widespread use of these drugs among athletes has, however, apparently prompted WADA to retain glucocorticoids in the banned list.

No credible defence

Coming back to the National Games context, the Tamil Nadu athlete tested positive for betamethasone, used in rheumatic disorders and treatment of allergic conditions, among others. He did not have much of a defence to present when he confronted the disciplinary panel headed by Mrs Gouri Karuna Mohanti.

The medicines that he claimed to have consumed mainly related to bronchial conditions. He also said he had taken some ayurvedic and unani medicines that he had been consuming over a long period of time.

“He apologized that he committed mistake and mentioned that he will accept the decision of the Panel”, stated the order.

The order goes on to say:

“As per the anti-doping rule of NADA 2015: 10.2.1 The period of ineligibility shall be four years where: 10.2.1.1 The anti-doping rule violation does not involve a specified substance unless the athlete or other person can establish that the anti-doping rule violation was not intentional.

10.2.1.2 The anti-doping rule violation involves a specified substance and NADA can establish that the anti-doping rule violation was intentional (emphasis mine).

“In the present case the anti-doping rule violation does involved (sic) a specified substance and the athlete was not able to establish that the anti-doping rule violation was not intentional” (emphasis mine).

The panel expected the athlete to prove his culpability while the rule demanded that NADA prove that he had intentionally doped. Otherwise, for specified substance the sanction should be suspension for two years.

The athlete was suspended for four years on the argument that he was not able to prove that the violation was “not intentional”, something that he was not required to do under the rules. It was NADA’s responsibility to prove that he had intentionally doped and that, even if it was proved by NADA to the satisfaction of the panel, is not explained in the order.

Wrester tests positive for three corticosteroids

Now, let us look at the other case, that of the female wrestler. She tested positive for not one but three different glucocorticosteroids, prednisone, prednisolone and betamethasone.

She argued that she had been prescribed medicines by a set of doctors for “severe back ache”. The prescription that contained tab medrol (which contained methylprednisolone) was issued to her in October 2014. Her sample was collected on 3^rd Feb, 2015.

NADA argued, as per the order, that the “presence of glucocorticosteroids cannot be consumed (sic) through the medicines as prescribed in the prescriptions. There is substantial gap between the last prescription and the date of the dope test.”

It was not mentioned in the order how long she had been taking the medicines and whether she took them right into the competition in the National Games. Prednisolone/prednisone (5mg) has a half-life of 18 to 36 hours, and betamethasone (0.75mg) 36 to 54 hours.

(Half-life means the time it takes for the drug in your system to drop by 50 per cent)

It was stated in the order that the anti-doping authorities were aware of the “ongoing condition” of her back just before competition. How this could have been possible has not been explained. Perhaps NADA was told of it at the time of sample collection or else she had written down her course of treatment and medications in the doping control form.

It was also stated that the athlete being of a village background did not have much knowledge of English and was not aware of the NADA rules. She had also never received “any formal anti-doping training or booklet”.

High concentration levels

Even though none of the substances was a threshold substance requiring the laboratory to provide concentration of the drug in the urine sample, NADA presented the following facts to the panel:

“Approximate rough concentration of substances: Prednisolone-191ng/ml, prednisone-317ng/ml, betamethasone-40ng/ml.”

The wrestler apparently claimed that she had applied Panderm Plus, a cream, to relieve pain. The medicine which can also contain clobetasol, a corticosteroid, is used for the treatment of skin rashes.

NADA pointed out that none of the prescriptions that she presented contained Panderm Plus. It need not have put forward an argument since the substances detected did not contain clobetasol.

The panel, chaired by Mr. Rajeev Kapoor, however concluded: “It is admitted case that the substances found in the sample was (sic) specified, therefore as per article 10.2.1 the ineligibility shall be for two years. In this case the athlete submitted that she consumed prednisolone, which contains the prohibited substance but same was prescribed by the doctor for severe back ache and not for performance enhancement. The athlete therefore showed and proved that how the substance entered in her body and therefore she is entitled to have reduced punishment.”

NADA argued in vain that the athlete “must have intentionally consumed the prohibited substance as the laboratory reports show that the sample contained different substances belonging to the same group.”

One medicine caused it all?

Apart from medrol, the drugs given in the prescriptions were Zerodol MR (combination of aceclofenac, a non-steroidal anti-inflammatory drug, tizanidine, a muscle relaxant, and paracetamol, anti-inflammatory and fever-reducing medicine), Rantac (antacid), Tryptomer 25 (anti-depressant) and a cough syrup.

Even if assuming that Medrol, which contained methylprednisolone, did contribute prednisolone (while failing to produce the parent drug methylprednisolone or any of its primary metabolites in the urine sample), how did Medrol and the rest of the medicines either together or singly produce betamethasone?

It was apparently assumed that the class of substances being the same (glucocorticosteroids), the presence of methylprednisolone in one of the medicines was enough to prove that the positive test for prednisone, prednisolone and betamethasone was established.

It has long been accepted, even in India, that a mere prescription is no certificate to consume banned drugs.

No clue what doping control form contained

The order of the panel did not mention whether the drugs claimed to have been prescribed for back ache were mentioned in the doping control form by the athlete.

How the substance entered an athlete’s body is the key clause that determines whether “no significant fault or negligence” (article 10.5.2) could be applied in a case. Though in this case there was no explanation as to how this had been proved, as NADA pointed out, the panel concluded:

“In view of the above, the panel has no hesitation in holding that athlete was successful in proving that (sic) how the substance had entered her body and according to article 10.5.1.1 the period of eligibility (sic) shall be reduced if the athlete re-established that she was not significant fault and negligence (sic). Therefore it is decided that the period of ineligibility in this case will be 1 (one) year which will start from the date of provisional suspension i.e. from 13-04-2015”.

At one stage the order states: “These seems (sic) that the athlete indirectly admits her guilt and nor in the position (sic) to explain which resulted (sic) in prohibited substance entered in her body”

Contradictory

Through the above paragraph, the panel has possibly suggested that the athlete could not explain how the prohibited substance entered her body. Yet the panel also concluded in its final summing up that the athlete was “successful in proving” how the substance entered her body!

Thus we have two cases of glucocorticosteroids use, ending in two drastically different sanctions. The Tamil Nadu athlete did not even know perhaps how to argue that his case came under ‘specified substances’ and it was up to NADA to prove that he had taken the banned substance intentionally. Otherwise the worst that he could have got was a two-year suspension. He got four.

The female wrestler, represented by a lawyer, managed to not only convince the panel that it had to go by the prescriptions she presented, though she did not have a TUE to use any of the medicines (and the prescribed medicines did not account for all the drugs detected in her urine sample), and oral administration of prednisolone/prednisone etc was clearly banned, but also that she deserved further reduction under the “no significant fault or negligence” clause.

The wrestler’s village background and lack of understanding of English and familiarity with NADA rules were cited in the order as mitigating factors. The fact that it was her first doping offence also went in her favour. Strangely the fact that she had not tested positive for a “masking agent” was also mentioned to drive home the point that she was not intending to dope!

It is not the first time that disciplinary panels in India have taken note of the “village background” of an athlete, lack of understanding of English, lack of education material having been made available to the athletes etc in reducing sanctions.

But then the Tamil Nadu 400m runner also confessed that he was unaware of the rules that stipulated application and approval for a TUE in case some prohibited medicines were to be consumed. Mere ignorance of rules and procedures did not provide an alibi for him. He did not even get the concession that the ‘specified substance’ allowed him under the anti-doping rules.

NADA will need to make enthusiastic efforts to counter this argument about lack of awareness regarding the rules by holding more ‘athletes outreach’ programme in the coming months and years if its anti-doping efforts have to prove successful.

WADA and NADA, apart from educating athletes and support personnel about doping and anti-doping measures, about the harmful effects of the drugs etc, will also need to hold workshops and seminars involving legal experts and international arbitrators to make Indian panel members acquaint themselves better with the provisions of the Code.

(updated 01-04-2016)