Can Asthma Medicines Be Used as "Performance Enchancers?"

Health Professional

Dara Torres has asthma, just like her father, says a story in the New York Times. But for years, she had been training and competing with coughing and difficulty breathing. When she finally started taking asthma medicine, "she realized how much, and how needlessly, she had been suffering."

But her newly found breathing capacity came with suspicions that her asthma was a sham and she was using the illness as an excuse to use bronchodilators -- the asthma medicines that relax the airways and improve breathing -- as a performance enhancer. And if she could use the albuterol inhaler, why couldn't everyone?

In this entry, I would like to give a perspective on the use of asthma medications by professional athletes. While most attention is given to the use of anabolic steroids to build strength, there has also been some attention to the use of asthma medications, especially albuterol and other quick-relief medications, in competitive athletes.

Competition with a chronic illness needing medication
There are many competitive athletes with chronic illnesses. I remember as a kid seeing Bobby Clarke, a hockey player for the Philadelphia Flyers, who lived and competed with juvenile onset diabetes. He led the team to two Stanley Cups and was inducted to the Hall of Fame in 1987. Due to the demands of his sport, he had to carefully balance his insulin and food intake around games. If he overshot or undershot he could not only feel sick, but not be able to play as well.

Few would suggest that Bobby Clarke should have been prevented from competing because he took regular medications. The reason is that there is no evidence that taking insulin is performance enhancing. This is the key to drug abuse in competitive sports: someone taking a medication not for illness, but to make them play better, be stronger, quicker, or have more endurance. Some medications are only used for this purpose and are banned from use by competitive athletes under all circumstances.

Yet, what about medications which are legitimately used to treat medical conditions but can also be abused? As explained by the chairman of the World Anti-Doping Agency, for a drug to be banned it must meet two of three criteria: 1) taking it must enhance or potentially enhance performance, 2) it could place an athlete's health at risk, or 3) it violates the spirit of sport.

Asthma medications
Asthma medications, especially quick-relief medications like albuterol, work by improving breathing capacity in an individual with asthma. Albuterol relaxes the smooth muscles around the breathing tubes (bronchi). If an asthmatic is wheezing, albuterol relaxes the tightened bronchial muscles and allows air to come in and out more easily. Any asthmatic knows that if they wheeze with exercise, they will wheeze less and be able to exercise better if they take a puff of albuterol.

So, one could ask whether a person without asthma might be able to further relax their bronchial muscles and increase their breathing capacity by taking albuterol. As it turns out, it doesn't work this way (at least by objective measures of lung function). If an asthmatic does a simple breathing test (spirometry) when they are not perfectly controlled, takes two puffs of albuterol, and repeats the spirometry 15 minutes later, there will typically be a significant improvement in breathing capacity (and the asthmatic will feel better). A non-asthmatic going through the same sequence will not have an improvement in breathing capacity. So, technically, albuterol is not a performance-enhancing drug in a non-asthmatic.

Should there be restrictions on albuterol in competition?
If albuterol is not performance enhancing, then shouldn't any competitive athlete be able to "give it a try?" Probably not. Like all medications, albuterol has side effects that can be harmful. That risk is far outweighed by the benefits for an asthmatic. For the non-asthmatic, the experimental use of albuterol could very well be banned -- it could place an athlete's health at risk, and taking it for kicks clearly violates the spirit of sport.

The sticking point is for athletes who have mild asthma or symptoms in certain situations or environments. Some athletes may train in clean air and feel fine but have asthma symptoms where there is more pollution.

This may well come up for the 2008 Olympics, where the Chinese government has already cut automobile use in the city by 50%, and may cut it down to 10% (which day residents can drive is determined by the last number of cars' license plates). There is a legitimate concern in the athlete community that individuals who are not taking regular medication and are not formally diagnosed with asthma may run into breathing trouble in Beijing, where their use of albuterol will be suspect as they do not carry a formal diagnosis.

Closing thoughts
There is clearly an "arms race" between athletes using performance enhancing drugs and the techniques they use to avoid detection and regulatory officials who want to maintain the spirit of fair competition and rightfully exclude those who violate the spirit of sport. However, there is no evidence that albuterol and other asthma medications can notably enhance performance.

Regulations should be enforced for all illicit use of medications. In my opinion, however, there would be a greater loss in a mild asthmatic missing out on a medal bid than a cheater potentially getting away with use of a medication that is unlikely to get them any farther or faster than going clean.

See also:

The 2008 Beijing Olympics Daily Update

Breathless in Beijing

Asthma and the Olympics: Air Quality May Be A Major Obstacle

Exercise Induced Asthma Is Just Another Challenge to Overcome