Bipolar disorders and comorbid conditions – Ethical considerations in sports

Introduction

The goal of pharmacologic intervention is therapeutic outcome – maximal efficacy with minimal adverse effects. In treating bipolar disorder, this may be complicated by comorbidities and/or adjunctive medications required to address adverse effects. Optimal rational polypharmacy may maximize therapeutic outcome yet could create ethical issues in competitive sports. The World Anti-Doping Code (WADC) and yearly published World Anti-Doping Agency Prohibited List are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. This paper presents three hypothetical examples (ADHD/lithium-tremor/pain) wherein unintended Prohibited List contravention would result in doping violation disqualifications without approved Therapeutic Use Exemptions (TUEs).

Method

Hypothetical case analyses with literature review.

Results

Comorbid ADHD – the Prohibited List precludes psychostimulants (methylphenidate/amphetamines) in competition (S6) but permits guanfacine/atomoxetine. When psychostimulants effectively treat ADHD in athletes with bipolar disorder but guanfacine/atomoxetine do not, these patient-athletes, with clinician's certification and supportive documentation, should file TUEs.

Lithium-tremor – beta-blockers are frequently prescribed to control lithium-tremor but are not permitted for specific sports (P2). If alternatives (primidone) are ineffective, TUEs are indicated.

Pain – chronic pain management is difficult in athletes as narcotic analgesics (S7) and cannabinoids (S8) are prohibited in competition. When comorbid pain is not controlled with approved medications, TUEs are required.

Conclusion

Patient-athletes with bipolar disorder and comorbidities require holistic approaches with appreciation of both the WADC and Prohibited List. Athletes should list all medications with diagnoses/obtain TUEs/verify proposed medication status (banned/restricted/permitted) with appropriate International Federations and/or Olympic organizations. Clinicians should be cognizant of these issues when treating patient-athletes.