Bad Sports, Part IV—The Air We Breathe

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Norway’s great champion, Martin Johnsrud Sundby, would lose his overall World Cup title and his Tour de Ski championship in 2015 over doping infractions related to the use of asthma medication nebulizers. Sundby had been the dominant figure in distance racing for a number of years before his disqualification, and the leader of a Norwegian team hounded by rumors regarding the absurdly high percentage of team members diagnosed with exercise-induced bronchoconstriction (EIB), commonly known as athletically-induced asthma. Sundby’s excessive use of a prescribed (and provisionally allowed) medication led to his disqualification.

In 2015, Sundby twice tested positive for excessive amounts of the substance salbutamol, commonly prescribed for those suffering from asthma. As an athlete who had been diagnosed with exercise-induced asthma, Sundby’s practice of administering salbutamol with a neublizer (a device that maximizes absorption) rather than a typical inhaler may have resulted in his exceeding the allowable amount (1600 micrograms over 24 hours).

That’s when the back-and-forth began . . . FIS said Sundby would not be disqualified, but the World Anti-Doping Agency (WADA) and the Court of Arbitration for Sport (CAS) ruled otherwise.

“While the medication is normally applied by a handheld metric dose inhaler (MDI), the athlete used a nebulizer to administer the prescribed salbutamol for the treatment of his asthma, which requires a higher labelled dosage than the MDI and thereby exceeded the allowed maximum dose,” FIS stated in its press release. “The FIS Doping Panel had therefore found that the athlete had not committed an anti-doping rule violation when he used a nebulizer as a legitimate means to administer salbutamol instead of a metric dose inhaler (MDI).”

WADA appealed the FIS Doping Panel’s decision, and CAS subsequently upheld WADA’s appeal resulting in Sundby receiving a two-month suspension. In contradicting the FIS ruling, CAS found that “the epithet ‘inhaled’ was meant to distinguish inhalation from other mechanics of inhalation like ingestion or injection and did not refer to the stage of administration (e.g. the amount that comes out of the device or which was eventually delivered to the athlete’s mouth or lungs). The allowed dose must be understood as the dose prescribed by the doctor, i.e. the ‘labelled’ or ‘nominal’ dose. Any higher dose, e.g. because of the need to use a nebulizer, requires a Therapeutic Use Exemption (TUE). When the tests were conducted in December 2014 and January 2015, the athlete was not in possession of a TUE and therefore found guilty of an anti-doping rule violation.”

Excessive Use

Ironically, the headlines surrounding Sundby’s infractions and suspensions did not result in comprehensive investigations of the widespread use of asthma inhalers by cross-country skiers, even though athletes and officials from rival nations had long complained of the apparent over-use of asthma medications by Norwegian skiers. Initial studies by the USOC in 2000 estimated that diagnoses of EIB among cross-country skiers that could reach 50%, an astronomically high figure suggesting problems that may exist within the sport itself. Either the athletic efforts associated with skiing actually created the condition, or athletes prone to the condition somehow gravitated toward skiing, or the methods of diagnosis were woefully inadequate. Medical descriptions of EIB admit that firm diagnosis is quite difficult because of the symptoms EIB shares with many other maladies (including asthma and heart conditions). The problem is that minor symptoms of EIB would also appear as though an athlete is merely fatigued, or simply out of shape. Amid such indefinite indicators, the diagnostic tool that most often identifies EIB is a simple question often asked by physicians: “Do you ever cough after intense and sustained athletic efforts.” That would seem to suggest that diagnoses of athletically induced asthma are disturbingly easy to receive, resulting in many skiers puffing away on inhalers prior to every race (and often every workout). Even in the junior ranks, use of inhalers is especially prevalent, and the result of such abuse has begun to be the prevalence of a suspicion that athletes who have not received such a diagnosis are competing at a disadvantage. Manufacturers and distributors of medications prescribed for EIB have repeatedly asserted that their use would offer no athletic advantage to those who do not actually suffer from the condition . . . but it’s easy to see how many could be skeptical of such claims when those medications are designed to help people breathe more easily and effectively.

EIB is a real condition, and one with which a reasonable percentage of skiers undoubtedly suffer. But as a long-time coach of junior skiers, I think we really should re-investigate the need for these medications, and the processes through which they are made so readily available to young athletes. Perhaps no solid answers will be found, but at least we will have reminded the ski community that these are drugs that our young athletes are inhaling, drugs designed to improve athletic performance. That simple step across a blurry ethical line is one that should concern us. Just ask Martin Johnsrud Sundby . . .