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| Representative photo |
Cross-country
runner Dinesh Kumar tested positive for terbutaline in the Services
cross-country championships in September 2017. In May 2018 he was handed
down a two-year suspension, the maximum that could be given for a ‘specified substance’
if the anti-doping authority fails to prove that the offence was intentional to
enhance performance.
This is the
maximum punishment ordered for a positive test for the bronchodilator drug in India since November,
2015. Four decisions preceding Dinesh Kumar’s had ordered mere ‘reprimand’. One
decision after Dinesh’s has ended in a one-year suspension for boxer Diksha
Rajput from 9 July, 2018.
So, why
should there be such great variance in sanctioning for terbutaline offences? Is
it possible to ingest it inadvertently, at least in the Indian context, since
athletes may not be familiar with the names of the banned substances that come
in cough syrups? Is it sufficient to show a medical prescription containing a
medicine that has terbutaline as one of its ingredients to at least get a
reduced sanction? This is an attempt to
analyze the various issues related to asthma drugs that are also commonly found
in many of the cough syrups.
Terbutaline
is a Beta-2 Agonist that forms a group of medications that help in relaxing the
muscles of the respiratory airways. Beta-2 Agonists are banned in sports by the
World Anti-Doping Agency (WADA) except for inhaled form of salbutamol,
formoterol and salmeterol, all asthma drugs, up to specified thresholds.
Asthma
patients among sportspersons apply for therapeutic use exemption (TUE) for use
of these drugs or corticosteroids for the management of their condition. As had
been reported in the distant past as well as recently, asthma medications tend
to be misused by athletes to enhance performance. Thus, through the years,
obtaining a TUE for asthma drugs has become tougher and tougher for the
athletes. It is also a fact that larger percentage of sportspersons seem to
suffer from asthma compared to the general populace.
Athletes vulnerable
Because of
the presence of some of these drugs in common cold and cough medications,
athletes have been particularly vulnerable to positive dope tests for Beta-2 Agonists
as well as stimulants like ephedrine, methylephedrine and pseudoephedrine, the
latter class of drugs mentioned in the prohibited list with specified permitted
thresholds.
Terbutaline
is available in tablet, syrup and inhaler forms. Athletes invariably claim that
they were advised cough syrups that contained terbutaline which they were
unaware of and thus turned in a positive dope test.
Generally,
hearing panels have tended to view the terbutaline offenders or the users of any
of the bronchodilators sympathetically even when they do not present TUEs and
only produce prescriptions.
In India, a
few of the more famous cases of terbutaline ingestion included that of
cricketer Yusuf Pathan and footballer Subrata Paul.
Pathan was slapped with a five-month ban by
the Board of Control for Cricket in India (BCCI) earlier this year for a
terbutaline offence in the Vijay Hazare Trophy in March, 2017. In July, 2017, Paul
was reprimanded, the lowest sanction possible for a ‘specified substance’ which
terbutaline is.
Yusuf Pathan gets five months
Pathan
promptly admitted his guilt and the BCCI agreed that the sanction would be five
months and backdated it to mean he would undergo just six days of the
suspension. Interestingly, Pathan was also deemed to have been under suspension
when he had actually played! BCCI having its own rules, based on ICC
anti-doping code, and its own hearing process, NADA was unable to intervene in
this case. Nor has NADA any authority to test cricketers in India, a tussle
that seemed to be headed for a showdown between the ICC and WADA if recent
reports are to be believed.
Subrata Paul
stated before a panel in a case brought forward by the National Anti-Doping
Agency (NADA) that the Indian team doctor had prescribed him Ascoril which
happened to contain terbutaline. The doctor admitted his guilt. The panel was
highly critical of the doctor and the All India Football Federation (AIFF).
In this
background has come Dinesh Kumar’s case. At the outset, it has to be clarified that a
mere medical prescription does not allow an athlete to take a prohibited drug.
For that you need a TUE. But a prescription does help often as had been found
in several cases.
Dinesh
Kumar’s sample given on 28 September 2017 turned in a positive result for
terbutaline. He appeared before the anti-doping disciplinary panel (ADDP)
headed by Mr. Kuldeep Singh. The panel also contained Dr Sanjeev Kumar and
hockey Olympian Jagbir Singh.
Dinesh, who hails from Jhunjhunu, Rajasthan, told
the panel that in August 2017 he was on leave and was suffering from fever and
cough. He was advised medicines by a doctor at “Saheed Chandrabhan Duddi
Memorial Hospital”, Laharu, Haryana. He was prescribed “Tab Augmentin Duo 625m
Zinetac 150mg, Montair LC, Syp Brozeedex and tablet Caproc 625mg on 28/08/2017”.
(All medicines as spelt out in the order)
The athlete
further stated that before the competition he was suffering from cough and
consumed ‘Brozeedex’ which was left in the bottle. He said he was not aware
that the cough syrup contained a prohibited substance.
NADA’s pet argument
On its part,
NADA simply stated what it had been stating ad nauseum: “It is each athlete’s
personal duty to ensure that no prohibited substance enter his or her body.
Athletes are responsible for any prohibited substance or its metabolites or
markers found to be present in their samples. Accordingly, it is not necessary
that intent, fault or negligence or knowing use on the athlete’s part be demonstrated
in order to establish an anti-doping rule violation under Article 2.1.”
NADA contended
that the athlete did not have a TUE to use the prohibited substance. It also
said that the athlete did not disclose the medicine at the time of the sample
collection in the doping control form.
Bro-Zedex (not
Brozeedex as mentioned in the order) contains terbutaline. The order does not
mention whether the athlete produced a prescription. It mentions a hospital where
the athlete reportedly went. The athlete has stated a few medicines including
Bro-Zedex (presumably) but the order does not say that these medicines are
contained in a prescription or a hospital OPD document.
Let us assume
then that there was a prescription. And it contained Bro-Zedex as one of the
medicines prescribed by a doctor. It doesn’t suffice of course as a substitute
for a TUE. But have panels been lenient in the past since there was a prescription?
“Yes” is the
unambiguous answer
Of the 14
cases of terbutaline listed on the NADA website, eight are pre-2016. Of them,
there were three for six-month suspensions, two for three months, one for one
year, one exoneration and one for two years. Boxer Vikas Singh suffered the
two-year suspension from March 2015.
After four
cases of ‘reprimand’ in 2016 came Dinesh Kumar. He is out for two years form
his voluntary provisional suspension date of 7 November 2017,with the panel not
even making a mention about his illness or the medicines or the absence of a
TUE in its order except as part of athlete’s submission.
The Kuldeep
Singh-headed panel observed that NADA had failed to establish “intentional”
doping (by which the athlete could have been suspended for four years) and thus
it had to be two years suspension.
The cough syrup in question
Two of the
four ‘reprimanded’ athletes (shot putter Suji Rani and wrestler Khushboo Pawar)
had used Bro-Zedex. They produced prescriptions, but they did not have TUEs. In
both cases the panels ruled that the athletes could not have derived any advantage
by using the cough syrup containing terbutaline.
Boxer
Amandeep Kaur used syrup Muconext which contained terbutaline. In her case also
the panel ruled that she could not have derived any performance-enhancement by
using the drug.
As mentioned
above, National football team goalkeeper Subrata Paul was also given a ‘reprimand’
when it was proved that the team doctor had prescribed a medicine that
contained terbutaline.
Does this
happen at the international level also?
Yes. British
cyclist Simon Yates was given a four-month suspension for a terbutaline offence
in 2016 when his team failed to apply for a TUE for his “long-term asthma”
problems. Yates apologized.
There are no
fixed criteria, it would seem, for accepting or rejecting a prescription or a
medical condition as mitigating circumstances for the positive test for such
drugs.
Precedents
in India showed prescriptions were fine. Some even suggested there was no
advantage by taking this drug from a performance angle. In a 2013 study, terbutaline
has been found to aid sprinters due its capacity to boost anaerobic performance,
but it “decreased endurance due to side-effects.”
No one
seemed to have guided Dinesh Kumar, an endurance runner, about these aspects.
Nor did the panel apparently go into such issues. It seemed keen to avoid treating
the case as “intentional doping” and slapping a four-year ban.
The order
was issued on 7 May and informed through a NADA letter dated 17 May, 2018. The
appeal deadline of 21 days from the receipt of the intimation has long been
over. May be, Dinesh would have fared better had he received some legal help.
Before we
start complaining that two years for a terbutaline offence looks too harsh,
just sample this one! Four years
for ephedrine! And the guy took it without a hearing!
