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Abstract
Aim We report on the results of the ‘IOC Needle Policy’ applied during the course of the Games of the XXXI Summer Olympiad in Rio de Janeiro, Brazil. The policy was intended to empower physicians to ensure appropriate clinical use of needles within team medical environments, enhance the safety of those responsible for housekeeping services and others in the Olympic environment, and permit documentation of such procedures as an adjunct to the doping control programme. Any needle use required the submission of an ‘Injection Declaration Form’ to IOC medical officials.
Method All ‘Injection Declaration Forms’ were reviewed and archived. The declarations provided basic information regarding the nature of the needle use and the product(s) involved, the physician, athlete and respective National Olympic Committee (NOC). The details of the declarations were subsequently categorised.
Results A total of 367 declarations were received from physicians representing 49 NOCs. Needle-use declarations were more common in athletics, gymnastics, football and aquatics. A single product was administered in 60% of the cases, and more than one product was administered in 40%. The majority of declarations indicated the use of local anaesthetics, glucocorticoids, non-steroidal anti-inflammatory drugs and analgesics.
Conclusion The introduction of a ‘Needle Policy’ in the Olympic Games setting was intended to minimise the use of needles by non-physicians, promote evidence-based practice and to deter needle-based doping practices. Declarations were received from 49 of 209 NOCs suggesting either that needle use is minimal among certain teams or opportunities remain to enhance compliance with such policies at future games.
- olympics
- IOC
- drug use
- sport
- athlete
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Introduction
In 2012, at the time of the XXX Summer Olympic Games in London, the Medical Commission of the IOC introduced, for the first time, a policy addressing the use of needles within an Olympic Games setting. Concerns had previously emerged regarding the degree to which needles and injections were being used by physicians and others in a manner which was not well understood. The development and application of this policy was spurred by: an increasing awareness of the possibility of doping behaviours facilitated by injection; a concern for the degree to which injections of an array of medications or other products were being administered by non-physicians; and, a recognition of the hazards posed by needle-stick injuries. It was anticipated that the application of this policy would empower team physicians by restricting the use of needles to physicians alone and requiring the documentation of such needle use, and enhance the quality of care provided in the Olympic environment.
The policy mandated that the use of any needle required the submission of an ‘Injection Declaration Form’ to the IOC Medical Commission Games Group. Such submissions were reviewed and archived; the process permitted an adjudication and oversight of injection and other needle-associated practices. The use of needles in association with the self-administration of insulin for diabetes, or other conditions declared and approved with a Therapeutic Use Exemption (TUE), and acupuncture therapy were precluded from this policy. Furthermore, injections administered at the polyclinic in the Olympic Village were not reportable through the Needle Policy—such use was considered to occur in the context of appropriate, and usually urgent, clinical practice—and are not considered in the following discussion. However, it was required that the administration of such injections administered in the polyclinic were appropriately documented in the clinical records. Physicians attending athletes and staff not residing in the Olympic Village were expected to complete declarations of any needle use in such settings.
We report below on an analysis of the results of the application of the policy during the Olympic Games Rio 2016, and are able to describe, for the first time, patterns of needle use by physicians in such a setting. Our findings will be of interest to all sport medicine physicians, sport administrators and those with responsibility for the development and implementation of healthcare and doping-control policies in settings involving elite international competitors and their entourage.
Methods
The Needle Policy
All team physicians attending the Olympic Games Rio 2016 were informed, both at the team physician meeting and in previous written communication, of the specifics of the ‘Needle Policy’. The policy mandated that the use of needles by anyone other than physicians was not permitted; that the use of a needle for injection or aspiration occurring during the period between the Opening and the Closing Ceremony required the submission of a needle-use declaration; and that appropriate care, custody and control of needles and arrangements for their proper disposal in safety containers was a responsibility of team physicians. Physicians were further advised that needle-use declarations could be submitted either electronically or in paper form by means of a deposit box in the Olympic Village Polyclinic pharmacy (see online supplementary figure S1). Forms submitted on paper were scanned, and transmitted to the offices of the IOC Medical Commission regularly throughout the day.
Supplementary file 1
The needle-use declarations captured basic data including the name of the athlete and physician (including country of medical registration and specialty) involved in any injection or other form of needle use; the relevant National Olympic Committee (NOC); the sport; date and place of injection; the substance injected; and a brief medical justification for the needle use (figure 1).
![[SP1.jpg]](https://bjsm.bmj.com/content/bjsports/52/11/747/DC1/embed/inline-supplementary-material-1.jpg?download=true){kind=link}
IOC Needle Policy injection declaration form for the Olympic Games Rio 2016.
Categorisation of substances administered
The needle-use declaration forms were collected and reviewed, and the substances identified therein were categorised appropriately as one of the following: a local anaesthetic, a glucocorticoid, a non-steroidal anti-inflammatory drug (NSAID), an analgesic, a vitamin, a homeopathic preparation, an immunisation, a viscosupplement, an anticoagulant, an intravenous administration, a gastrointestinal function and motility agent, an antibiotic, a mineral, a muscle-relaxant, an antihistamine, platelet-rich plasma or a benzodiazepine. Declarations that indicated the use of needles for aspiration purposes were labelled as aspiration. Substances that did not fit this classification system were labelled as miscellaneous. Substances that were not disclosed, illegible or unknown were labelled as indeterminate.
Results
Characteristics of needle-use declarations
At the Olympic Games Rio 2016, 367 needle-use declarations were declared and submitted in accordance with the IOC Needle Policy. From among the 367 needle-use declarations, 221 (60%) identified the administration of a single substance and 145 (40%) declarations indicated the administration of two or more substances. There were eight (2%) declarations identifying multiple administrations of the same substance(s), for example, anticoagulants. These declarations were counted singly. Eight such declarations indicated a total of 62 separate injections; these were not included in the overall total number of administrations (table 1).
Needle-use declaration summary
From among the 207 NOCs represented at the Olympic Games Rio 2016, physicians caring for Olympic athletes from 49 NOCs submitted one or more needle-use declarations. Of the 367 needle-use declarations, 285 separate athletes were identified as the recipient of an injection. Of the 285 athletes documented, 141 (49%) of the athletes were female and 143 (50%) of the athletes were male. The gender of one athlete was listed as ‘unknown’ (illegible declaration). The mean age of athletes for whom declarations were submitted was 27 years ; six of whom were under the age of 18 years . There were 16 (6%) athletes under 20 years of age, 178 (63%) athletes were between 20 and 29 years old, 82 (29%) athletes were between 30 and 39 years old and 7 (2%) athletes were 40 years of age or older. One declaration did not disclose a date of birth (table 1).
Needle-use declarations by sport
Declarations were received from 26 of the 28 sports in which a competition took place at the Olympic Games Rio 2016. No declarations were received involving competitors in Golf or Modern Pentathlon. Athletics (117; 32%), gymnastics (25; 7%), football (25; 7%), aquatics (22; 6%) and volleyball (18; 5%) were the sports with the highest number of needle-use declarations, respectively (table 2).
Needle-use declarations by sport (n=367)
Substances administered
A total of 589 administrations of various substances were identified within the 367 needle-use declarations. Local anaesthetics (162; 28%), glucocorticoids (106; 18%), NSAIDs (71; 12%), analgesics (58; 10%) and vitamins (31; 5%) were the most commonly administered substances, respectively. Local anaesthetics (52; 32%), glucocorticoids (36; 34%), analgesics (37; 64%) and vitamins (31; 5%) were most commonly administered to athletes in athletics, while NSAIDs were most commonly administered to athletes in gymnastics (13; 18%) (table 3).
Needle-use administration summary (n=589)
Among the declarations identifying the injection of a single substance, NSAIDs (42; 11%), local anaesthetics (40; 11%), glucocorticoids (32; 9%), immunizations (23; 6%) and analgesics (18; 5%) were the most commonly administered substances. Within declarations that identified the administration of two or more substances, combinations of local anaesthetics, glucocorticoids, analgesics and NSAIDs with an additional substance(s) were the most frequently administered. Local anaesthetics were administered with an additional substance(s) in 31% (115) of all declarations; glucocorticoids were administered with an additional substance(s) in 18% (18%) of all declarations; analgesics were administered with an additional substance(s) in 11% (40) of all declarations; and NSAIDs were administered with an additional substance(s) in 8% (29) of all declarations. A remaining 4% (14) of declarations indicated the administration of two or more substances, but did not include a local anaesthetic, glucocorticoid, NSAID or an analgesic (table 4).
Needle-use declarations identified by single or multiple substances
Discussion
We report, for the first time, the unique patterns of needle use by physicians in an Olympic Games setting. These data demonstrate the frequency with which physicians employed needles in caring for Olympic athletes, the prevalence and nature of any substances administered, and the patterns of needle use in certain sports.
Minimal needle use was observed among athletes at the Olympic Games Rio 2016
Medication and supplement use among Olympic athletes is quite common. The majority (54%–74%) of Canadian athletes competing in the Olympic Games Atlanta 1996 and Sydney 2000 used some form of medication or supplement.1 Among Japanese athletes selected as candidates for the 2012 Olympic team, 82% used at least one supplement prior to competition.2 A substantial majority (64%–79%) of athletes selected for doping control or who had applied for a TUE at the Olympic Games Sydney 2000, and the Olympic and Paralympic Games Athens 2004, declared the use of a medication or supplement.3–5
While the use of medications and supplements among elite athletes is common, it is more typical to administer these substances orally; 91% and 89% of the athletes from the 2004 Olympic and Paralympic Games respectively declared substance use by oral administration at the time of doping control, whereas only 4% and 7% reported receiving injections.4 5 It is perhaps not surprising, therefore, that physicians caring for 11 237 athletes from 207 NOCs participating in the Olympic Games Rio 2016, submitted only 367 needle-use declarations, and from among those declarations, only 285 (2.5%) athletes from 49 NOCs were identified as the recipients of needle use.
The IOC Needle Policy requires medical staff to declare needle use; nevertheless, this policy has its limitations. It is the responsibility of team physicians to ensure appropriate needle-use practices and the submission of needle-use declarations. Thus, the extent to which needle use took place but was not declared is unknown; the number of needle-use declarations is likely not representative of all needle use that may have occurred. Furthermore, a number of smaller NOCs did not have medical staff present at the Olympic Games and therefore relied on the polyclinic for the appropriate medical care. This may have resulted in a larger number of athletes and respective NOCs being identified if the injections administered in the polyclinic were reportable through the Needle Policy. It is assumed, however, that the needle use administered to those NOCs was insignificant in contrast to the larger NOCs with medical staff.
Needle-use differences among NOCs
An analysis of the data in the needle-use registry indicates that certain NOCs more commonly submitted declarations, suggesting disproportionate rates of submission between and among NOCs. Interpretation of these results raises various questions that remain unanswered. More frequent needle use within certain NOCs may reflect that their team physicians were more assiduous in complying with the policy. Alternatively, it may reflect typical medical practice of such team physicians and a culture of routine needle use within certain sports and their athletes.
If we were to assume that significant needle use occurred without the appropriate documentation, the lack of declarations from the other 158 NOCs may suggest a lack of rigour in documenting medical practices, an intention to hide inappropriate practices or the concealment of doping-related practices involving needle use. At the present time, we do not have data that would permit an objective assessment of compliance with the policy.
Nature of substances administered within needle-use declarations
As previously noted, the majority of declarations consisted of the administration of a single substance (60%), most typically NSAIDs (11%), local anaesthetics (11%) and glucocorticoids (9%). A substantial proportion (40%) of declarations indicated the administration of multiple substances. It was intriguing to note the combination of substances that were administered: local anaesthetics were identified in 31% all declarations when two or more substances were administered. An analysis of the appropriateness of such combination therapies is beyond the scope of this review. Others have undertaken an examination of approaches to analgesic use in caring for elite athletes.6 7
The results from the needle-use registry differ from studies that have shown that vitamins and NSAIDs are the most common substances used by Olympic athletes.1 3–5 Such substances are, of course, more commonly orally administered precluding any comparisons with the current injection-related data. The high use of local anaesthetics and glucocorticoids documented by our analysis is not surprising, given that these substances are typically administered by injections.
Although declarations were received from only a minority of NOCs and involved a small number of competitors, it is possible that needle use and the administration of certain substances may be more prevalent among elite Olympic athletes; these findings derived, from an Olympic setting, may not be applicable to other sporting environments. It is reasonable to assume, however, that the introduction of needle-use policies might be anticipated in other multisport or major competition settings. The collection and publication of data surrounding these practices permits greater understanding of needle use, and in the future might be expected to further enhance optimal, evidence-based sport medicine practice; deter the use of needles by non-physicians; reduce the risk of needle-stick injuries; and deter needle-based doping strategies in those environments.
Needle-use differences between sports
A number of investigators have identified that ‘individual’ sports typically demonstrate the highest rates of supplement and medication use in contrast to their ‘team-based’ counterparts.1–6 These findings are similar to those revealed in our analysis of the needle-use registry. The sport with the highest number of needle-use declarations at the Olympic Games Rio 2016 was athletics. Thirty-two per cent of all declarations revealed needle use among competitors in athletics; 7% of declarations involved players in football; 7% of declarations involved competitors in gymnastics; and 6% of declarations documented needle use among competitors in aquatics. Documented needle use within football, however, included a high number of influenza vaccine administrations.
A tendency of competitors in athletics to make frequent use of vitamin, mineral and other dietary supplements has previously been noted.1 3 5 We have identified that significant needle use is commonplace in this sporting discipline; almost one third of reported needle use took place in athletics. Such use could be due to a higher incidence of injuries or conditions that warrant injection treatments employing local anaesthetics, other analgesics, glucocorticoids or NSAIDs. Or rather, our findings may merely reflect the great number of competitors within the multiple athletic disciplines, who constituted 47 out of all 306 events at the Rio 2016 Games.
Impact of the IOC Needle Policy
We do not have confidence in assuming that our data accurately reflect the totality of needle use at the Olympic Games. Others have previously identified the challenge of ensuring accurate and complete documentation of needle use in an Olympic Games setting.8 It could be assumed that the declarations of needle use (589 uses documented in 367 declarations over the 2-week period of the games), demonstrate an awareness among physicians of the importance of such declarations and significant compliance with the policy; given that this is the first report of such use no comparisons are currently possible. We do not have data to objectively assess whether there was a reduction in needle-stick injuries, an intended goal of the policy, as relevant data were not available—it is assumed, however, that the elimination of needle use and their inappropriate disposal by non-physicians in a variety of settings would reduce the likelihood of such injuries. During the Olympic Games Rio 2016, the WADA Sport Physicians Tool Kit was made available to all team doctors.9 The contents included information on the Needle Policy which may have contributed to increased compliance with the policy. Similarly, it is reasonable to assume that the information shared at team physician meetings may have played a role in stimulating adherence to the policy, notwithstanding that while attendance at the meeting is strongly encouraged it is not mandatory.
We would note that on several occasions a completed needle-use declaration provided documentary evidence of the permitted route of administration of a glucocorticoid which was subsequently detected in doping control tests and initially, and appropriately, adjudged an ‘Adverse Analytical Finding’; the need for further investigations of such findings was therefore eliminated. While the submission of needle-use declarations was mandatory, and the possibility of disciplinary action via the IOC Medical and Scientific Commission and the IOC Executive Board existed, no such actions were undertaken to address a failure to report during the Rio Games.
We have made no attempt in our review to judge the clinical justification or appropriateness of needle use. Such examination may usefully form the basis of future studies, recognising that there may be widely varying opinions as to what constitutes appropriate needle use. In the future, an electronic means of completing declarations would expedite the application of this policy; an analysis of the number of injectable products dispensed by the Polyclinic Pharmacy would provide further information regarding needle use by physicians. Continued collection of this information at future Olympic Games will be necessary in order to answer these questions and provide information to guide the further evolution and implementation of a needle-use policy.
In summary, the Needle Policy was intended to enable team physicians to ensure appropriate use of therapies administered in the Olympic environment, and to prevent inappropriate utilisation of needles by non-clinicians or other non-qualified individuals. The policy permits an overview of injectable drug administration and other needle uses in an elite sport environment in order, to the extent possible, to empower clinicians, to ensure safety and to deter the use of needle-based prohibited drug administration. We would make the assumption that the introduction of such a policy has sensitised athl8etes, physicians and other members of the athletic entourage of the issues surrounding inappropriate needle use. We would recommend further, more detailed examinations of the effect of such a policy and an expanded education and awareness programme regarding the policy at future Olympic Games. It is important that clinicians receive evidence-based guidance regarding the use of injectable products, and understand the lack of evidence of the effectiveness of the injection of many of the products noted in the declarations we have reviewed. Ultimately, we wish to ensure that athletes receive only evidence-based, clinically justified treatments.
What are the findings?
We report on the declarations of needle use at the Olympic Games Rio 2016.
Local anaesthetics, glucocorticoids, non-steroidal anti-inflammatory drugs and analgesics were the most commonly administered substances.
The majority of declarations consisted of the administration of a single substance (60%), but the administration of multiple substances was also prevalent (40%).
Needle use was most common in athletics, gymnastics, football and aquatics.
How might it impact on clinical practice in the future?
This manuscript will sensitize clinicians to the issues surrounding the use of injections and other forms of needle use in caring for athletes. It is to be hoped that it will contribute to ensuring that athletes receive evidence-based appropriate clinical treatments.
Acknowledgments
The administrative assistance of Cherine Touvet-Fahmy during the course of the Olympic Games Rio 2016 was greatly appreciated. We wish to acknowledge the contributions of
our clinical colleagues who conscientiously completed and submitted needle-use declarations.
Footnotes
Contributors MA participated in the data analysis, manuscript preparation and review. HG participated in the data collection and manuscript review. MCS participated in the data collection, manuscript preparation and review. RB participated in the data collection, manuscript preparation and review. AP participated in the data collection and analysis, manuscript preparation and review.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.