Interested to hear people’s thoughts on using painkillers for performance enhancement in sports.
Have you done it?
Do you think using over the counter painkillers (Ibuprofen, Paracetamol) is ok?
Where does this become a grey area or even a line drawn on using stronger stuff?
In the past, pro cyclist have openly talked about the use of “finish bottles” basilcy loads of painkillers & caffine mixed into a drink.
Next year Tramadol will be added to the in competition prohibited list (many years behind cycling).
In a recent podcast, they were talking about how Tramadol is problty being used to num pain in races
But like many Opioids it has a drowsiness effect. So loads of caffeine is also injested to negate this.
Can definitely think of a high profile athlete who is well know for high caffine intake before a race.
I will chime in with a hopefully authoritative view on some aspects of this.
My job is as an anesthesiologist, which to those who don’t know too much about what we do, it is basically applied pharmacology and applied physiology, along with a lot of acute and chronic pain management.
Firstly, on the issue of paracetamol/acetaminophen. It is very safe and you need to use considerable doses to really have an effect on your liver. Generally 90mg/kg per 24 hours are safe. We will use a loading dose of 30mg/kg in an acute pain setting or in the peri-operative setting. If I am carrying an injury etc and have to function I will often pop 1.5 grams myself. You really run into problems from a liver perspective when you go above this 90 mg/kg/24hours. So taking some before and during races should not be too much of an issue.
Secondly: anti-inflammatories. These are often ideal as pain relief for many sports related injuries and therefore commonly used to help get people through races. But, they have significant issues and you really need to be careful. The biggest one to be worried about in a racing and training environment is the effects of dehydration combined with NSAIDs on renal blood flow, and hence the ability to cause an acute kidney injury. You have to be super careful and really careful in terms of your fluid management. I personally took some during an Ironman as I was fighting some niggles on the run so took them before hopping off the bike, but I would be loathe to recommend this to others. They have well known effects on your gastric mucosa and can cause ulcers and gastritis, so some people need to take them with something to protect their stomach lining, like ranitidine or omeprazole. (not sure what the USA terms are for these). They are also not recommended in people with hypertension although still commonly used as generally we need these medications in elderly patients with arthritis etc.
Thirdly: opiate/partial opiate agonists (ie tramadol). Tramadol is a partial opioid agonist that also has effects on a few other pain pathways. I have to admit to being surprised when I first read about this being used in cycling. Then I guess it made sense, not so much as a direct performance enhancer, but more so a performance enhancer because of its greater ability to dull pain than “simple” analgesics. As others have mentioned, the drug can cause some sleepiness, but this really depends on the individual tolerance to it and the dose used. We don’t find drowsiness a big issue in normal clinical use. You can easily combat this with some caffeine if needed, but I don’t think you will find the cyclists using massive doses of caffeine to counteract this effect. Those that have used it may be able to agree with this next statement-the side effects can be incredibly variable. We have a distinct group of patients who just refuse to ever use it again as it made them feel horrible. They can get all sorts of neurological/cognitive side effects like inability to sleep, hallucinations etc from it. These are unpredictable, you never quite know who is going to get that. I have rarely used this myself from an injury perspective, in part as I have been prescribed other things normally. We definitely see more of these adverse side effects in our female population.
There are other partial opioid agonists that are out there which are commonly used for analgesia, including Palexia (tapentadol) and Temgesic (Buprenorphine). Only buprenorphine and tramadol are on the 2024 WADA list so I imagine that tapentadol may become the default go to agent in this regard. It is a much newer agent to all the others but I am surprised it has not made the WADA list.
