It’s time to finally ban tramadol in cycling: A pharmacist’s view

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For years now there have been loud calls from within cycling to ban tramadol from competition. This strong painkiller has reportedly been used by many riders to dampen feelings of pain, allowing them to push harder than they might have otherwise. But despite widespread concern about the drug — including from the UCI — the World Anti-Doping Agency (WADA) has held firm, refusing to add tramadol to its banned list.

So how widespread is tramadol’s use? Does it enhance cycling performance? And should it be banned, as so many are advocating for? Darren Searle is an Australian pharmacist of 15 years and a keen racing cyclist. In the following article he tells you everything you need to know about tramadol, and explains why he believes it’s high time for the drug to be banned.

What is tramadol and how does it work?

Tramadol is a centrally acting analgesic (painkiller), which displays opioid-like effects. However, unlike traditional opioids – such as morphine or codeine — tramadol is not derived from natural sources, nor is it chemically related to opioids. Tramadol is a synthetic chemical.

There are two ways in which tramadol is thought to work. For a start, the liver converts tramadol into a molecule commonly called M1 (officially mono o-desmythyltramadol). M1 then binds to one of the body’s opioid receptors, which is responsible for pain relief. In addition, tramadol can increase the levels of noradrenaline and serotonin within the body. This can result in a “feel-good” effect, which can add to the pain-relieving effects of tramadol.

Tramadol is available in the form of an immediate release capsule (50mg) and a sustained release tablet form (50mg, 100mg, 150mg and 200mg). Additionally, it also comes in an oral liquid formulation, as well as a solution for injection.

Like all medications, tramadol has a long list of side-effects. Very common side-effects (occurring in greater than 1 in 10 people) are dizziness and nausea; common side effects (greater than 1 in 100 people) include headaches, dry mouth, perspiration, sedation, general weakness, vomiting, constipation and fatigue.

How strong is tramadol?

When comparing tramadol to more familiar opioids, the analgesic properties are actually quite surprising. Analgesic effects and dose conversions will vary between individuals, but based on general clinical data, one 50mg oral dose of tramadol has equivalent analgesic effects to:

– 10mg of morphine, or
– 7mg of oxycodone, or
– 75mg of codeine.

As a reference point, a single Endone tablet contains 5mg of oxycodone; slow-release morphine tablets range from 10mg to 100mg in strength; while Panadeine Forte tablets each contain 30mg of codeine (combined with paracetamol). If you’ve ever been prescribed these opioids in the past — after surgery or for broken bones, say — you would appreciate just how strong a single dose of tramadol can be by comparison.

How frequently is it prescribed and why?

Traditional opioids (with the exception of codeine when combined with paracetamol) are highly regulated. Tramadol, however, does not fall into the same category as opioids, so the regulations surrounding its prescription are not as strict.

While many doctors are still reluctant to prescribe tramadol on a regular basis — given the potential for abuse within the general community — in excess of 2.6 million tramadol prescriptions were dispensed over the 12 months from July 1, 2016 to June 30, 2017.

Here in Australia, to be approved by the Therapeutic Goods Administration — a section of the Department of Health which regulates therapeutic goods — a drug has to have a listed use. For tramadol, this is for the “relief of moderate to severe pain”. Further to this, when listed on the Pharmaceutical Benefits Scheme (PBS), medications often need a patient to meet specific clinical criteria before they can be prescribed and subsidised by the government. The PBS criteria for tramadol is a condition for which “aspirin and/or paracetamol alone are inappropriate or have failed”.

This is where “off-label” prescribing comes in. As long as a doctor sees a “genuine clinical need” for a patient to have a medication, they can prescribe it outside of the listed guidelines. Hence, some doctors may be prescribing tramadol off-label for cyclists when it may not be the best choice of pain relief.

Of course, “genuine clinical needs” are open to interpretation. Many doctors have gotten in trouble with the Australian Medical Association (AMA) for prescribing medications when the need is questionable. Dare I mention triamcinolone at this point?

Can tramadol enhance cycling performance?

Theoretically, tramadol itself won’t actually provide any performance benefits. It won’t make muscles stronger, it won’t increase oxygen supply, it isn’t a stimulant. What it can do is allow athletes to push their physical limits further. By acting as an analgesic and suppressing an individual’s sensation of pain, tramadol may allow riders to push themselves just a little bit harder, which can then lead to better performances.

In addition, the effects of tramadol on noradrenaline and serotonin can improve the mood of an athlete. In theory, this can also help to improve performance — it’s a lot easier to push yourself a bit more when you’ve got a positive mindset.

Not surprisingly, there is very little scientific research regarding the performance-enhancing benefits of tramadol. Perhaps the most-referred-to study came from the University of Granada in Spain in 2017 and involved a 20-minute cycling time trial and two separate exercises during that time trial.

The results for exercise 1 showed a small increase in average power output in the tramadol group compared to placebo. There was also an increase in average heart rate for the tramadol group, as well as a higher level of fatigue and confusion. Exercise 2 included a behavioural task during the time trial. Results showed no increase in power output during the time trial but evidence did show that tramadol had an effect on brain function related to stimulus-processing when compared to placebo.

These results show that yes, tramadol use can lead to performance improvements, but it can also mean athletes have to concentrate harder and may experience greater fatigue and higher levels of confusion. Obviously, during a mass-start cycling race, this can create danger for others.

How widespread is its use among cyclists?

In the course of writing this article I spoke to a handful of cyclists of different levels across several disciplines: national and international mountain bikers, cyclocross racers of a similar level, and roadies from Australia’s National Road Series (NRS) and at a Pro Continental level. From these conversations it would seem that tramadol use is not widespread. A handful of riders at an NRS level reportedly use it, but not consistently. Its use in other disciplines appears minimal at best.

When it comes to the highest level of the sport, however, things might be slightly different.

There are stories of tramadol being dissolved in bidons, so they are readily available for riders when they feel the need for it (often at the end of a race). American rider Taylor Phinney spoke to CyclingTips reporter Shane Stokes (then working for VeloNation) about this issue in October 2012.

“Some people find it surprising that riders would take painkillers or caffeine pills in races, but it is actually really, really common,” Phinney said. “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.

“There is widespread use of ‘finish bottles’, which are just bottles of crushed-up caffeine pills and painkillers. That stuff can make you pretty loopy, and that is why I have never tried it. I don’t even want to try it as I feel it’s dangerous.”

Former UCI president Brian Cookson painted a similar picture in 2016, telling CyclingTips “we are pretty clear that this is something that is being abused.”

Technically, there’s nothing wrong with riders using tramadol — it isn’t a banned substance. But at the same time, there is. Team doctors are pushing their off-label prescribing rights to the limit, giving riders access to a very strong analgesic without first performing a proper medical examination. Not only is this putting the health and safety of the individual cyclist at risk, it may also be risking the safety of others in the race.

Is tramadol safe?

As with any medication, the user of tramadol needs to consider the drug’s benefits against its risks. For those in the general population who need strong pain relief due to injuries — yes, tramadol is safe for its intended use. Of course, many of the side-effects of tramadol are undesirable and often force people to stop taking it. However, many are willing to tolerate these side-effects if it means adequate relief from a painful condition. Imagine dealing with a broken wrist, say, without any form of pain relief.

Is it safe for cyclists though? Based on the potential for drowsiness, delayed reaction times, and lost concentration, I would suggest that riding a bike while on tramadol is not a smart idea. Not only are you risking a crash yourself, but you are also risking the safety of those around you.

In addition, if you have an injury severe enough to require pain-relief this strong, you should probably let your injury heal before getting back on the bike.

Should tramadol be banned?

According to the World Anti-Doping Code, a substance or method should be included on the prohibited list if it meets two of the three following criteria:

– If it “has the potential to enhance or it enhances sport performance”
– If it “represents an actual or potential health risk to the athlete”
– If its use “violates the spirit of sport”.

In terms of tramadol, it can be argued that the research does show a potential for the substance to enhance sports performance, even if it is indirectly. There is also a potential health risk to athletes, both as a result of tramadol’s side-effects and its ability to mask pain, which may lead to further or worsening injuries.

Additionally, when comparing tramadol to opioids which are already on the prohibited list — including morphine and oxycodone — one might question why tramadol isn’t also on the list. The analgesic properties and side-effect profiles are very similar, so it would make sense for tramadol to be a banned substance.

Further to this, when it comes to “the spirit of sport”, the WADA code refers to, among other things: ethics, fair play and honesty; health; and respect for self and other participants. The use of tramadol while competing could be seen to go contravene some if not all of these values.

As it currently stands, the use of tramadol is still legal in cycling, despite the best efforts of the UCI. For years now, the governing body has lobbied WADA for tramadol to be on the banned list, but to no avail. In the past few years, the UCI has even considered implementing its own tramadol ban, but the legal implications of that have the potential to be tricky.

Other agencies have attempted to push for a ban, too. The US Anti-Doping Agency is among them while the MPCC, the “Movement for Credible Cycling”, has also pleaded with WADA, twice, to ban tramadol. Both of those attempts were unsuccessful.

So what’s WADA’s approach to tramadol? Since 2012, the drug has been part of the agency’s monitoring program, allowing WADA to collection additional information on its use before implementing a ban. For now, WADA remains unconvinced that tramadol satisfies two of the three criteria necessary for a ban, also suggesting that its use widespread use as an analgesic means it shouldn’t be banned.

In a response to the MPCC’s 2017 call for tramadol to be banned, WADA replied:

“In 2015, Tramadol was considered for inclusion on the [Prohibited] List but, as it may be legitimately prescribed as part of a therapeutic regimen in certain situations, the majority of stakeholders felt that it should not be prohibited but rather be regulated by physicians, and physician groups, as part of proper medical practice.”

Should tramadol be allowed as pain-relief to help treat injuries? Absolutely. Should it be allowed in competition? No. But that’s just my opinion. You are free to form your own conclusions.

Ultimately, the final decision on whether it becomes a banned substance or not lies with WADA.

For much more information about tramadol, how it works, its safety profile and more, check out this 2017 review by the World Health Organisation.

About the author

Darren Searle is a qualified pharmacist of 15 years who has spent his career working in dispensaries of retail pharmacies across Adelaide. Outside of his daily duties as a pharmacist, he is an avid racing cyclist. Beginning his cycling endeavours as more of an irregular recreational activity, his passion steadily grew and he started his racing career at the age of 31. He now trains most days of the week, with a focus on road races and time trials.

Darren is the founder and author of The Sports Pharmacist, a site all about health, medications and sport.

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