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Abstract
Objectives We describe compliance with the ‘IOC Needle Policy’ at two Winter Olympic Games (Sochi and PyeongChang) and compare these findings to those of the Summer Olympic Games of Rio de Janeiro.
Method All needle-use declaration(s) (NUD) received during the course of the 2014 and 2018 Olympic Games were reviewed. We recorded socio-demographic data, the nature and purpose of needle use, product(s) injected, and route of administration. Data were analysed descriptively.
Results In total, doctors from 22 National Olympic Committees (NOCs) submitted 122 NUD involving 82 athletes in Sochi; in PyeongChang, doctors from 19 NOCs submitted 82 NUD involving 61 athletes. This represented approximately 2% of all athletes at both Games, and 25% and 20% of all NOCs participating in Sochi and PyeongChang, respectively. No marked differences in the NUD distribution patterns were apparent when comparing the two Winter Olympic Games. The most commonly administered substances were as follows: local anaesthetics, non-steroidal anti-inflammatory drug and glucocorticoids. Physicians submitted multiple NUD for 24% of all athletes who required a NUD.
Conclusion A limited number of NOCs submitted NUD suggesting a low incidence of needle use or limited compliance (approximately 2%). A key challenge for the future is to increase the rate of compliance in submitting NUD. More effective education of NOCs, team physicians and athletes regarding the NUD policy, its purpose, and the necessity for NUD submissions, in association with the enforcement of the appropriate sanctions following non-compliance are needed.
- IOC
- Olympics
- drug use
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Introduction
In 2011, as part of an effort to ‘to protect the health of athletes and to fight against the use of prohibited substances and methods in sport’, both the International Rowing Federation1 and the International Cycling Union2 created and introduced a ‘No Needles Policy’ which prohibited the injection of any substance without medical justification. The International Olympic Committee (IOC) adopted this concept and, for the first time, its Medical Commission mandated the submission of a needle-use declaration (NUD) at the time of any use of a needle at the 2012 Summer Olympic Games in London.3
The IOC Medical & Scientific Commission implemented this policy4 in response to emerging concerns regarding potential doping scenarios employing injections; inappropriate medical use of injections based on poor evidence of their safety or effectiveness; evidence of injections being administered by non-physicians and the known incidence of needle injuries at previous Olympic Games.4 According to the IOC, aims of the policy were to ensure that ‘appropriate steps are taken so that all injectable materials are stored in a central secured location’3 and ‘all injections are performed by medical staff for a medical reason’.5
Protection of the health of the athlete is core to the fundamental mission of the IOC Medical & Scientific Commission.6 7 The NUD policy aims to support this while empowering and supporting team doctors to use injections according to good medical practice. The policy does not apply to acupuncture-needle use or self-administered insulin therapy and excludes the injection of medications for which Therapeutic Use Exemptions (TUE) have been granted. Injections administered at the polyclinics in the Olympic villages by Sochi and PyeongChang Olympic Games Organising Committee physicians did not require a NUD since it was expected that all treatments and procedures in the polyclinics would be administered for legitimate medical reasons reflecting evidence-based clinical practice, and include safe needle-disposal procedures. Comprehensive electronic medical records of clinical encounters were maintained in the polyclinic setting which recorded the details of treatment and the administration of any medications by injection.
Failure to respect the IOC Needle Policy, including failure to submit a completed NUD to the IOC Medical & Scientific Commission and/or the use of injections without appropriate clinical justification, may expose an athlete, an athlete’s entourage, the National Olympic Committee (NOC) and members of its delegation as well as the person(s) having administered the injection to disciplinary action in accordance with Article 59 of the Olympic Charter.8 This is clearly stated in the IOC Needle Policy.
The first report describing the NUD process during a Summer Olympic Games was published in 2018, describing the Rio 2016 Olympic Games.4 During this event, 367 declaration forms were reviewed from physicians representing 49 NOCs. The most frequent use of needles was among athletes competing in athletics, gymnastics, football and aquatics. In more than 40% of injections, at least two different products were administered. Most declarations documented the injection of local anaesthetics, glucocorticoids, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics.
The aim of this report was to analyse the NUDs from the Sochi 2014 Olympic Winter Games (where the needle policy was first introduced in a Winter Olympic setting) and those from the PyeongChang 2018 Olympic Winter Games. We compared the data from Sochi with those from PyeongChang to detect possible differences in the number of needle declarations, the use of particular medications; an examination of the Rio data4 permitted a comparison of practice between Summer and Winter Olympic Games.
Methods
A description of the NUD process was sent to all participating NOCs 1 year prior to the Olympic Games and elements of the NUD process were further communicated to the NOCs at the team physician meeting held in the Olympic Villages prior to the Opening Ceremony. The policy stipulated that all injections administered by a physician between the Opening and Closing Ceremony had to be declared and justified by completing and submitting a NUD to the IOC Medical & Scientific Commission. NUDs were available in paper and electronic formats and physicians could either e-mail them or drop them into a letterbox in the reception area of the polyclinic pharmacy within the Olympic Villages. The polyclinic pharmacists managed the collection process and ensured the security of the forms prior to collection by a representative of the Therapeutic Use Exemption Committee (TUEC).
Prescriptions for injectable products that were dispensed by the polyclinic pharmacy were provided to NOC physicians with specific instructions regarding the completion of a NUD prior to their administration. The dispensing pharmacists would also ensure that the drug and intended route of administration were not prohibited in sport according to the World Anti-Doping Agency (WADA) List of Prohibited Substances and Methods. If the drug or intended route was prohibited by WADA, both the NOC physician and the respective athlete were informed that they had to apply for a TUE prior to administering the medication.
Information to be provided on the NUD included socio-demographic data (name of the athlete and physician, athlete’s date of birth, NOC and sport of the athlete) as well as the medical justification for the injection(s), substance(s) injected, and the place of administration.9 If multiple daily injections were deemed necessary, one NUD was submitted on each day the injection was administered.
In Sochi and PyeongChang, all NUDs were reviewed by members of the TUEC who, when deemed appropriate, were able to question a team physician about an injection if additional clarification or confirmation of the appropriateness of the needle use was required.
For purposes of data analysis, NUDs were categorised as follows: analgesic, antibiotic, anticoagulant, anti-emetic, carnitine, glucocorticoid, expectorant, homoeopathic, immunisation, infusion (radiology), local anaesthetic, mesotherapy, mineral, wound drainage, NSAID, platelet-rich plasma, vaccination and vitamin. NUD forms with missing or illegible information were categorised as ‘not defined’.
Data are presented both in combination and separately for each Olympic Winter Games (Sochi and PyeongChang). In addition, independent T-tests were applied to analyse possible differences in number of administered NUD and multiple substances between the two Olympic Games. To calculate the highest rates of NUD submissions by NOC, the absolute numbers per NOC were stratified based on the number of athletes of the respective NOC. The level of significance was set at p<0.05 and if applicable 95% CI were provided.
Results
Compliance with the needle-use policy
In total, 122 and 84 NUDs concerning 82 and 61 athletes were administered during the Winter Olympic Games in Sochi and PyeongChang, respectively. The relative number of athletes who were the subject of a NUD was 2.87% in Sochi and 2.09% in PyeongChang. On average, 1.49±1.0 (Sochi) and 1.38±0.15 (PyeongChang) NUDs were administered per athlete. Multiple NUD per athlete constituted 28% of the Sochi declarations compared with 18% of the PyeongChang declarations (p=0.16.). Sochi athletes for whom a NUD was submitted had a mean age of 27.4±5.3 years compared with the mean age of 26.9±4.9 years of PyeongChang athletes. There are no significant differences between the number of NUD at the two Winter Olympic Games or the socio-demographic characteristics of the athletes.
Most athletes for whom NUDs were submitted in Sochi participated in Alpine skiing (22.0%, n=18), freestyle skiing (15.9%, n=13), snowboard (15.9%, n=13) and Bobsleigh (6.1%, n=5). In PyeongChang, Alpine skiing (21.3%, n=13) was followed by Freestyle skiing and Bobsleigh (both 18%, n=11), speed skating (9.8%, n=6) and snowboard (8.2%, n=5).
Stratifying by NOC size (number of athletes per NOC), most NUDs were submitted by Liechtenstein (33.3%), Monaco (20%) and Andorra (16.7%) in Sochi and by Belarus (25%), Germany (9.6%) and Great Britain (6.9%) in PyeongChang. (figure 1)
Nationalities of athletes for whom NUD were submitted stratified by NOC size. NOC, National Olympic Committee; NUD, needle-use declaration.
The origin of NUD
With regard to the submission of NUD (including multiple NUD per athlete), the sports most frequently involved were Alpine skiing (27.9% Sochi, 22.6% PyeongChang), snowboard (20.5% Sochi, 16.7% PyeongChang) and freestyle skiing (10.7% Sochi, 15.5% PyeongChang). In total, NUDs were submitted by physicians of 22 NOCs in Sochi (25% of all participating NOCs, n=88) and 19 in PyeongChang (20.4% of all participating NOCs, n=93) (table 1).
Ranked Country-specific distribution of NUD
Substances administered
In Sochi, 174 substances were injected; 118 substances were injected in PyeongChang. These were part of 122 and 84 NUD, respectively, with a mean for Sochi of 1.44±0.81 (range: 1–4) and for PyeongChang of 1.4±0.66 (range: 1–4; p=0.71). In Sochi, 27% (n=33); CI 95% (19% to 35%) NUD indicated more than one substance was to be administered compared with 32.1% (n=27); CI 95% (22% to 42%) in PyeongChang (p=0.55). Of those declarations indicating the administration of more than one substance, an average of 2.58±0.75 (range: 2–4) substances were administered in Sochi compared with 2.26±0.53 (range: 2–4) in PyeongChang (p=0.07).
The nature of the substances administered, the sports and the NOC involved at both Olympic Games are outlined in tables 2 and 3.
Substances administered per sport and Olympic Games
Distribution of number of NUD and substances per sport
At both Olympic Games, intravenous administration of a substance was the route most often indicated (24.3%; CI 95%: 18% to 30%) on a NUD, followed by intralesional (IL; 20.9%; CI 95%: 15% to 27%; ie, infiltration into or around an area of concern, such as ligament and tendon insertion sites), intra-articular (IA; 20.2%; CI 95%: 15% to 25%) and intramuscular (15.1%; CI 95%: 11% to 19%) administration. In Sochi, intravenous administration was the route most commonly indicated (26.4%) followed by IL (22.4%), IA (17.8%) and intramuscular (16.1%). During the PyeongChang Olympic Games, IA was the route most commonly indicated on a NUD (23.7%; CI 95%: 15% to 33%) followed by intravenous (21.2%; CI 95%: 12% to 30%), subcutaneous (SC)(20%), IL (18.6%) and intramuscular (13.6%) (figure 2).
Route of administration. IA, intra-articular; IL, intralesional; IM,: intramuscular; IV, intravenous; SC, subcutaneous; ND, not defined/not readable.
Discussion
This report provides data describing the patterns of needle use declared by clinicians at the 2014 and 2018 Olympic Winter Games. It follows a previous publication describing such patterns at a Summer Olympic Games.4 Similar to the summer experience, we report few submissions of NUD during the Winter Olympics.
In total, doctors from 22 NOCs in Sochi and 19 in PyeongChang submitted 206 NUD involving 143 athletes—approximately 2% of all athletes. The athletes were members of 25% of all participating NOCs in Sochi, and 20% of NOCs participating in PyeongChang. This number seems to be very low and one could assume a low rate of compliance even though there is a risk of sanctions to both competitors and physicians following non-compliance with the NUD policy. However, as noted by Allen et al,4 the true number of injections and thus NUD that would have to be submitted cannot be quantified. Also, the reasons for failure to submit a NUD cannot be evaluated. Our results should be interpreted with this in mind.
When we assessed the origins of NUD based on NOC size, it was apparent that most NUDs in Sochi were submitted by rather small countries such as Liechtenstein, Monaco and Andorra. In PyeongChang, Germany and Great Britain were among the top three NOCs submitting NUD. As in the Summer Olympic Games in Rio, the most commonly administered substances were local anaesthetics, NSAIDs and glucocorticoids.4 Overall and based on the total numbers from both Olympic Winter Games, most NUDs were submitted from Alpine skiing, freestyle skiing and Bobsleigh. The route of administration identified most frequently was intravenous followed by IL and IA. In PyeongChang, however, IA was the route of administration most commonly identified and intravenous and SC ranked second and third.
Overview: our data in the context of injections during international sport events
Details on the number of injections administered in the course of other international sports events are scarce but indicate similar, low rates of injection use.9–14 Those reports suggest, as do our findings, that the injection of minerals, supplements and vitamins are common in elite sport settings. An examination of the medication use by athletes at the Sydney Olympic Games 2000 (as declared on 2759 doping control forms) reveals that 78% of athletes reported taking medications and supplements,10 51% declared vitamins and 25.6% NSAIDs. 4.5% of vitamins and 4.3% of NSAIDs were administered via injections. During the Summer Olympic Games 2004 in Athens, 45% of all athletes declared the use of medications or food supplements on their doping control forms. Injections were identified in 3.8% of all declarations mainly local and IA injections of glucocorticoids and NSAIDs.11 A similar investigation during the Athens 2004 Paralympic Games reported the use of medications or nutritional supplements in 64% of all participants.11 Injections made up 6.7% of the total and were mostly food supplements, NSAIDs and local anaesthetics. Most analgesics were taken orally; only 12% of NSAIDs were injected. An examination of the doping control forms of 3887 top-level track and field athletes revealed that 2.7% reported having received local anaesthetics or corticosteroid injections during the preceding 7 days12. At the Fédération Internationale de Football Association (FIFA) Football World Cup (South Africa 2010), 71% of all players took medications during the tournament.13 In 3.3% of all cases, medications were administered via injection. In a retrospective survey of the use and abuse of medications during the 2014 FIFA World Cup in Brazil, 134 of 2346 players received injections, mainly glucocorticoids (3.1% of all medications) and local anaesthetics (2.6% of all medications).14
‘Good clinical practice’ for needle use
As an essential rule of good clinical practice, the principle of non-maleficence (‘do no harm’) must be applied to physicians participating at an Olympic Games.15 The pressure for rapid recovery and pain relief placed on team physicians and athletes from different parties (including athletes themselves) is particularly great during an Olympic Games. Standards and recommendations regarding pain management in elite athletes are published and available; they are the basis for pain management provided by NOC physicians.16 17 Medication should be provided in accordance with the manufacturer’s licensed product information for safe clinical use—a concept, applicable to all patients.
We noted a high frequency of needle use for pain therapy: 36% local anaesthetics, 12% NSAIDs and 9.2% glucocorticoids during both Winter Olympic Games. It is important that physicians are aware of the optimal route of administration of such medications considering their risk–benefit ratio and, of course, the needle-use policies now in place in an Olympic setting. It was suggested, during discussions with NOC physicians during the Olympic Winter Games 2018, that there are country-specific differences in the practice of injecting pain medications. There is still debate regarding the intramuscular administration of local anaesthetics and NSAIDs, since there is moderate to strong evidence that intramuscular injection could be myotoxic18 with a synergistic effect on myotoxicity when combining local anaesthetics with glucocorticoid injections.18 That intramuscular injections for pain control may be more frequent by some team doctors in the treatment of athletes is evident when considering the use of the injectable form of the NSAID ketorolac.19
Based on our NUD data, the intramuscular administration of a substance was the fourth most common route of administration during the last two Olympic Winter Games. In addition to the injection of local anaesthetics and NSAIDs for pain management, administering other substances via injection such as glucocorticoids should be critically evaluated. In the era of evidence-based medicine, sport and exercise medicine practices must be subject to careful, thoughtful scrutiny. Providing and administering medicines, by any route, should adhere to the principles of good clinical practice and accord with the rules governing the use of medications and other substances in sport developed by WADA.20
The need for such critical evaluation in the sports setting is particularly relevant for non-regulated preparations or supplements including homeopathic injections, minerals and vitamins (table 2). The needle declaration process continues to show that athletes are being administered such products, which have limited or no evidence of safety and effectiveness.21–23 There is an additional risk of potential contamination of non-regulated supplement preparations with prohibited substances.22 There is a need, in our view, for the development of evidence-based guidelines addressing certain practices employed by clinicians in sport medicine settings. These could be done by, for example, the IOC, WADA, but also sport medicine associations have the responsibility to ensure and support evidence-based best practice. The IOC recently addressed the areas of analgesic and supplement use in published consensus statements, which are aimed at improving the quality and safety of athlete care.16 22 One goal of the needle policy is to strengthen awareness among NOC doctors of the importance of considering the correct therapy based on well-founded evidence of effectiveness and safety, and to consider the most appropriate route of administration.
Limitations and future aspects
A key challenge for the future of the NUD process is to find ways to quantify the true number of administered injections that would require a NUD. Assuming that our hypothesis, that the low prevalence observed in our study is associated with a low compliance rate, is true, another challenge will be to improve the rate of compliance with needle-use regulations and ensure the appropriate submission of NUD by physicians during an Olympic Games. It is surprising that team physicians from fewer than 20% (19 of 93) NOCs submitted a NUD during the Sochi and PyeongChang Olympic Games. The most benign explanations are as follows: (a) as most small NOCs do not have their own team physician, any injections of athletes from these NOCs were likely administered in the polyclinic and not registered; (b) athletes from countries that submitted no NUD received injections only from physicians in the polyclinic of the Olympic Villages or designated partner hospitals or (c) team physicians of more than 80% of all NOCs did not inject any medication.
We are concerned that some team physicians did not declare injections via the NUD process. If this is the case, there is a need for the IOC to better educate both NOCs and their team physicians regarding the background, purpose and submission of NUD prior to and during the Olympic Games. This could be facilitated by formally communicating with all registered medical staff prior to the respective Olympic Games, encouraging attendance at the team physician meeting, and by ensuring access to the details of the NUD process throughout the Olympic Games. The use of social media and other innovative, contemporary approaches to the education of team physicians could be of great assistance. It may be reasonable to assume that as familiarity with these processes develops that compliance with the NUD policy will increase. Nevertheless, given that the experience of clinicians in an Olympic setting and their levels of specific sport-medicine experience may vary widely, and recognising that many smaller teams may not be accompanied by a physician suggest that ongoing education challenges will remain.
What are the findings?
Doctors from 27 National Olympic Committees (NOCs) submitted 206 needle-use declarations (NUDs) for 143 athletes reflecting approximately 2% of all athletes and 25% and 20% of all NOCs participating at Sochi and PyeongChang, respectively.
Substances administered most commonly by injection were local anaesthetics, non-steroidal anti-inflammatory drugs and glucocorticoids.
Intravenous administration of a substance was the route most often indicated followed by intralesional, inta-articular and intramuscular injections.
How might it impact on clinical practice in the future?
Low prevalence of NUD might be an indicator of low compliance with the needle declaration process which, if true, needs to be strengthened through targeted education of both team physicians and athletes, and enforcement of sanctions for non-compliance with the policy. Since doctors of fewer than 20% of all NOCs currently declare clinically justified injections at the Olympic Games, effective education of NOC team physicians and athletes regarding the purpose of the IOC Needle Policy and submission process prior to and during the Olympic Games is essential.
Acknowledgments
The authors thank Cherine Touvet-Fahmy for her assistance in the administration of the NUD processes.
References
Footnotes
Contributors WS participated in the data collection, data analysis, manuscript preparation and review. CB participated in the data analysis, manuscript preparation and review. AP participated in the data collection and manuscript review. RB participated in the data collection and manuscript review. MS participated in the data collection, manuscript preparation and review.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests No, there are no competing interests for any author.
Patient consent for publication Not Required
Ethics approval information The study is based on an analysis of an administrative database and the manuscript contains no personal medical data information about identifiable persons. The results utilise completely anonymised data regarding the completion of the NUD by physicians at the respective Olympic Games. Thus, ethical approval is not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.