The Essential and Optimal Analgesic and Anti-Inflammatory Medicines for Athletes at the Olympic Games.

BACKGROUND: In 2019, the International Olympic Committee published the first Olympic and Paralympic Model Formulary (OPF), which defined the standardised set of medications required at every Olympic and Paralympic Games for the treatment of athletes. This study aimed to test the OPF to determine whether it meets the clinical needs of the athlete population with respect to medications used for pain and/or inflammation (PI), and to present a revised set of essential PI medications for the OPF based on prevalence of athlete use. Medication-use data of athletes at the Tokyo 2020 and Beijing 2022 Olympic Games (n = 6155) from three sources were used to establish prevalence of PI medicine use and to revise the OPF: (i) doping control forms, (ii) pharmacy dispensing reports, and (iii) injection declaration forms. This revised list was further validated through (iv) medication importation declarations by teams (n = 156), and (v) survey of team physicians (n = 382). RESULTS: Overall prevalence of PI medication use was 36.7%, with higher use by female athletes (female: 44.1%; male: 30.0%; p < 0.001), with non-steroidal anti-inflammatory drugs being the most used class (27%). Use of medications with safety risks were identified, including nimesulide, piroxicam and metamizole. A revised list of 48 PI medications was recommended for the OPF. CONCLUSION: The research led to a revised set of essential medications for the treatment of pain and inflammation to be available for athletes at the Olympic Games, which would lead to a 7% improvement in the numbers of athletes who could have their exact PI medication requirements met by the OPF.

The Tokyo 2020 Olympic and Paralympic pharmacy services during the COVID-19 pandemic.

BACKGROUND: During the Tokyo 2020 Games, pharmacists were required to provide appropriate pharmacotherapeutic care to athletes and officials at the polyclinic. Owing to the worldwide COVID-19 pandemic that was prevalent at the Games, it was imperative to strengthen infection control measures in the setting of such a major sporting event and to prevent and minimize the spread of COVID-19. OBJECTIVE: This study reports on the COVID-19 infection control measures and services provided by the pharmacy at the Tokyo 2020 Games. By evaluating pharmacy operations that took place under the COVID-19 protocol, this study provides insights for the organization of future sporting events, specifically their medical facilities. METHODS: Infection control measures in the pharmacy were implemented in accordance with the manual for dealing with COVID-19 infections. The number and content of issued and dispensed prescriptions were obtained from the electronic medical records and pharmacy department systems. These data were compared with those of the London 2012 Games, which were used as a reference for the pharmacy operations at the Tokyo 2020 Games. RESULTS: The participating pharmacists were fully trained in infection control measures. The number of prescriptions issued during the Olympics and Paralympics were 1120 and 1022, respectively. Prescriptions issued at the fever clinic accounted for 4% of the total number (77/2142). No influenza antiviral medications were prescribed, though medications to alleviate cold-like symptoms were issued. Compared to the London 2012 Games, there was a decrease (-59%) in the number of prescriptions. CONCLUSION: The positive impact of COVID-19 infection control measures was evident. The volume of prescriptions at the Tokyo 2020 Games was lower than that at the London 2012 Games. It was inferred that this was due to thorough infection control measures as well as enhanced pre-entry medical checkups before entering Japan, which reduced the incidence of diseases.

Pharmacy services at the Tokyo 2020 Olympic and Paralympic Games: perspectives of the pharmacy workforce.

OBJECTIVES: To evaluate the awareness of the volunteer pharmacy workforce of medication use and their satisfaction with the pharmacy services of the Tokyo 2020 Olympic and Paralympic Games from a pharmacist's perspective. METHODS: A questionnaire was developed from related articles in published peer-reviewed journals and modified prior to distribution to the whole population of pharmacists serving at the Tokyo 2020 Olympic and Paralympic Games. Validity tests were conducted based on expert opinions and Cronbach's alpha (0.79). The questionnaire consisted of demographics (11 questions), knowledge of medication use in sports (8 questions) and satisfaction on the provision of the service (5 questions). Responses using a 5-point-Likert scale, from strongly agree (5) to strongly disagree (1), and two free text questions were analysed with descriptive statistics. RESULTS: The response rate was 86% (n=32/37). Overall, the pharmacists reported a high awareness of medication use. Specifically, questions on the prohibited list of medications (mean 4.0±SD 0.7), COVID-19 policy (3.8±0.9), use of alternative non-prohibited medications (3.6±1.0) and therapeutic use exemptions (3.5±0.9). Moreover, they rated high satisfaction with the pharmacy service they provided. However, rates were ≤3 for knowledge of the International Olympic Committee Needle Policy (2.6±1.0), Medication Importation Declaration (2.9±1.0) and communication skills (3.0±1.0). CONCLUSION: Pharmacists were confident and satisfied with the pharmacy service at the games. The study confirms the importance of prior training and education. Game-specific policies and strategies to improve communication skills should be included in the pharmacy education for future Games.

Inequalities in the disruption of paid work during the Covid-19 pandemic: A world systems analysis of core, semi-periphery, and periphery states.

This article reveals the extent of international inequalities in the immediate impact of the COVID-19 pandemic on participation in paid work. Drawing on World Systems Theory (WST) and a novel quasi-experimental analysis of nationally representative household panel surveys across 20 countries, the study finds a much sharper increase in the likelihood of dropping out of paid work in semi-periphery and periphery states relative to core states. We establish a causal link between such international disparities and the early trajectories of state interventions in the labor market. Further analysis demonstrates that within all three world systems delayed, less stringent interventions in the labor market were enabled by right-wing populism but mitigated by the strength of active labor market policies and collective bargaining.

Thyroid Hormone Abuse in Elite Sports: The Regulatory Challenge.

Abuse of androgens and erythropoietin has led to hormones being the most effective and frequent class of ergogenic substances prohibited in elite sports by the World Anti-Doping Agency (WADA). At present, thyroid hormone (TH) abuse is not prohibited, but its prevalence among elite athletes and nonprohibited status remains controversial. A corollary of prohibiting hormones for elite sports is that endocrinologists must be aware of a professional athlete's risk of disqualification for using prohibited hormones and/or to certify Therapeutic Use Exemptions, which allow individual athletes to use prohibited substances for valid medical indications. This narrative review considers the status of TH within the framework of the WADA Code criteria for prohibiting substances, which requires meeting 2 of 3 equally important criteria of potential performance enhancement, harmfulness to health, and violation of the spirit of sport. In considering the valid clinical uses of TH, the prevalence of TH use among young adults, the reason why some athletes seek to use TH, and the pathophysiology of sought-after and adverse effects of TH abuse, together with the challenges of detecting TH abuse, it can be concluded that, on the basis of present data, prohibition of TH in elite sport is neither justified nor feasible.

Surgical planning during a pandemic: Identifying patients at high risk of severe disease or death due to COVID-19 in a cohort of patients on a cataract surgery waiting list.

BACKGROUND: The delivery of cataract surgery during the COVID-19 pandemic is challenging because of the risk of nosocomial SARS-CoV-2 infection when patients attend hospital for elective care. In order to ascertain the risk to patients awaiting cataract surgery, this study aimed to identify the presence of systemic comorbidities that are associated with a high risk of severe disease or death due to COVID-19. METHODS: A prospective study of 315 patients (630 eyes) was conducted from 3rd June to 31st July 2020. An electronic health record was used to identify any systemic comorbidities that would render a patient 'clinically extremely vulnerable' to COVID-19, as outlined by the Department of Health for Northern Ireland. Patient demographics, best-corrected visual acuity (VA) and risk of postoperative anisometropia were also recorded. RESULTS: The median age of patients awaiting cataract surgery was 76 years (range 22-97). Of the 315 patients, 72% were aged over 70 and 16% were aged over 85. A systemic comorbidity that would confer high risk status was identified in 21% of patients. This high risk status was attributable to severe respiratory disease, cancer, and immunosuppression therapies in the majority of cases. The high risk group were younger than those deemed non-high risk, but there were no significant differences with respect to gender, anticipated degree of surgical difficulty, VA, or whether the patient was undergoing first or second eye surgery. Of those patients awaiting first eye cataract surgery, the mean VA in the listed eye was 0.84 logMAR and 39% (70/179) had a VA <0.3 logMAR (6/12 Snellen acuity) in their fellow eye. 57% of patients were awaiting first eye surgery, and 32% of those patients would be at risk of symptomatic anisometropia postoperatively. CONCLUSION: One-fifth of patients awaiting cataract surgery were found to be at high risk of severe disease or death from COVID-19 and these patients may experience delays in their surgical care. Additional planning is required in order to minimise the morbidity associated with delayed cataract surgery.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology.

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Patterns of Athlete Medication Use at the 2018 PyeongChang Paralympic Games: A Descriptive Cohort Study.

OBJECTIVE: Medication use among elite athletes has received growing attention over the past decades. However, only limited studies have focused on para athletes, and trends in medication use among this cohort remain unclear. The aims of this study were (1) to describe the pattern of medication use in elite Paralympic athletes, with a particular focus on analgesics, (2) to analyze whether medications declared by athletes were included in the 2018 World Anti-Doping Agency's prohibited list and monitoring program, (3) to report on a variety of novel supplements, and (4) to review whether athlete analgesic needs will be met by the new Olympic & Paralympic Model Formulary. DESIGN: This is a retrospective, descriptive cohort study. RESULTS: Of all athletes who underwent doping control, 21% declared the use of an analgesic medication. Athletes with limb deficiency and para snowboarders declared the most analgesic medications in their respective categories. It was determined that 84% of the athletes' analgesic medication needs were provided from the new Olympic & Paralympic Model Formulary. CONCLUSIONS: Analgesic use among athletes who participated at the 2018 PyeongChang Winter Paralympics was high. Para snowboarders and athletes with limb deficiency declared the most analgesics. The new Olympic & Paralympic Model Formulary adequately addressed the medication needs of the athletes attending the 2018 games.

A novel approach to improve detection of glucocorticoid doping in sport with new guidance for physicians prescribing for athletes.

The systemic effect of glucocorticoids (GCs) following injectable routes of administration presents a potential risk to both improving performance and causing harm to health in athletes. This review evaluates the current GC antidoping regulations defined by the World Anti-Doping Agency and presents a novel approach for defining permitted and prohibited use of glucocorticoids in sport based on the pharmacological potential for performance enhancement (PE) and risk of adverse effects on health. Known performance-enhancing doses of glucocorticoids are expressed in terms of cortisol-equivalent doses and thereby the dose associated with a high potential for PE for any GC and route of administration can be derived. Consequently, revised and substance-specific laboratory reporting values are presented to better distinguish between prohibited and permitted use in sport. In addition, washout periods are presented to enable clinicians to prescribe glucocorticoids safely and to avoid the risk of athletes testing positive for a doping test.

Athlete health and safety at large sporting events: the development of consensus-driven guidelines.

All sport events have inherent injury and illness risks for participants. Healthcare services for sport events should be planned and delivered to mitigate these risks which is the ethical responsibility of all sport event organisers. The objective of this paper was to develop consensus-driven guidelines describing the basic standards of services necessary to protect athlete health and safety during large sporting events. By using the Knowledge Translation Scheme Framework, a gap in International Federation healthcare programming for sport events was identified. Event healthcare content areas were determined through a narrative review of the scientific literature. Content experts were systematically identified. Following a literature search, an iterative consensus process was undertaken. The outcome document was written by the knowledge translation expert writing group, with the assistance of a focus group consisting of a cohort of International Federation Medical Chairpersons. Athletes were recruited to review and provide comment. The Healthcare Guidelines for International Federation Events document was developed including content-related to (i) pre-event planning (eg, sport medical risk assessment, public health requirements, environmental considerations), (ii) event safety (eg, venue medical services, emergency action plan, emergency transport, safety and security) and (iii) additional considerations (eg, event health research, spectator medical services). We developed a generic standardised template guide to facilitate the planning and delivery of medical services at international sport events. The organisers of medical services should adapt, evaluate and modify this guide to meet the sport-specific local context.

Compliance with needle-use declarations at two Olympic Winter Games: Sochi (2014) and PyeongChang (2018).

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.

Invited review: Intergovernmental Panel on Climate Change, agriculture, and food-A case of shifting cultivation and history.

Since 1990, the Intergovernmental Panel on Climate Change (IPCC) has produced five Assessment Reports (ARs), in which agriculture as the production of food for humans via crops and livestock have featured in one form or another. A constructed database of the ca. 2,100 cited experiments and simulations in the five ARs was analyzed with respect to impacts on yields via crop type, region, and whether adaptation was included. Quantitative data on impacts and adaptation in livestock farming have been extremely scarce in the ARs. The main conclusions from impact and adaptation are that crop yields will decline, but that responses have large statistical variation. Mitigation assessments in the ARs have used both bottom-up and top-down methods but need better to link emissions and their mitigation with food production and security. Relevant policy options have become broader in later ARs and included more of the social and nonproduction aspects of food security. Our overall conclusion is that agriculture and food security, which are two of the most central, critical, and imminent issues in climate change, have been dealt with an unfocussed and inconsistent manner between the IPCC five ARs. This is partly a result of not only agriculture spanning two IPCC working groups but also the very strong focus on projections from computer crop simulation modeling. For the future, we suggest a need to examine interactions between themes such as crop resource use efficiencies and to include all production and nonproduction aspects of food security in future roles for integrated assessment models.

Pharmacy services at the PyeongChang 2018 Olympic and Paralympic Winter Games.

OBJECTIVE: Pharmacy services at large multisport events support safe and effective medication use. Our aim is to describe the contribution of pharmacists and to share the pharmacy experiences at the 2018 PyeongChang Olympic and Paralympic Games. METHODS: The data collected included the accreditation details of patients and prescribers indicating: sport, country, athlete or non-athlete status, and prescription details including: medication, strength, frequency, length of treatment, for the period of the Olympic Games (1-26 February 2018) and the Paralympic Games (5-20 March 2018). The numbers of prescriptions dispensed were analysed by medication category, sports and country of the patient. RESULTS: A total of 5313 medication items were dispensed over the course of the Olympic and Paralympic Games (athletes: 670; non-athletes: 4615; unknown: 28), for a total of 2360 patients. 72 of 82 countries (87.8%) had fewer than 20 patient visits. The first high peak (Olympic: 5.0%; Paralympic: 7.3%) of daily volume of prescriptions were dispensed in the 2 days prior to the Olympic and the 1 day prior to Paralympic opening ceremonies. Therapeutic Use Exemption (TUE) and International Olympic Committee NeedlePolicy were well managed and compliant with the regulations. CONCLUSION: Pharmacy services at major multisport games include dispensing over 5000 prescriptions, supporting the TUE and IOC Needle Policy processes and providing clinical information to athletes and prescribers on drugs in sports and the World Anti-Doping Agency regulations of drugs prohibited in sport. During the PyeongChang 2018 Olympic and Paralympic Winter Games, pharmacists played a crucial role in delivering safe and effective pharmacy service based on their expert knowledge in antidoping and the clinical use of drugs in sport.

Instructional design and assessment of an elective course on the use of drugs in sport.

BACKGROUND AND PURPOSE: The use and misuse of drugs in sport is becoming increasingly important globally, and the role of pharmacists is evolving in this regard. This paper describes the design and implementation of an elective course "Drugs in Sport" in an undergraduate pharmacy curriculum. EDUCATIONAL ACTIVITY AND SETTING: The elective course was designed to introduce BSc pharmacy students to an evidence-based approach to safe, effective, and legal use of drugs in sport. The course covered why athletes take drugs, evolution of doping in sport, the international regulations regarding doping and anti-doping in sport including the World Anti-doping Agency Prohibited List, as well as testing and monitoring for drug use in sport. It also included the role of athlete support personnel (ASP) in preventing the use of prohibited substances by athletes. A web-based survey was conducted at the end of the course to assess the students' perspectives of the course. FINDINGS: Students provided an evaluation of the course in terms of its content, methods of delivery, and assessment. Overall, the students demonstrated competence. They gained insight into international and national regulations regarding doping and anti-doping in sport and the potential role of pharmacists as ASP in providing support and advice for athletes and the public. SUMMARY: Designing and implementing an evidence-based course on the use of drugs in sport customized for pharmacy students was achieved successfully. Such courses could provide an opportunity to advance the scope of pharmacy practice and possibly provide a new career path for future pharmacists.

Analgesic Management of Pain in Elite Athletes: A Systematic Review.

OBJECTIVE: To identify the prevalence, frequency of use, and effects of analgesic pain management strategies used in elite athletes. DESIGN: Systematic literature review. DATA SOURCES: Six databases: Ovid/Medline, SPORTDiscus, CINAHL, Embase, Cochrane Library, and Scopus. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Empirical studies involving elite athletes and focused on the use or effects of medications used for pain or painful injury. Studies involving recreational sportspeople or those that undertake general exercise were excluded. MAIN RESULTS: Of 70 articles found, the majority examined the frequency with which elite athletes use pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anesthetics, and opioids. A smaller set of studies assessed the effect of medications on outcomes such as pain, function, and adverse effects. Oral NSAIDs are reported to be the most common medication, being used in some international sporting events by over 50% of athletes. Studies examining the effects of pain medications on elite athletes typically involved small samples and lacked control groups against which treated athletes were compared. CONCLUSIONS: Existing empirical research does not provide a sufficient body of evidence to guide athletes and healthcare professionals in making analgesic medication treatment decisions. Based on the relatively robust evidence regarding the widespread use of NSAIDs, clinicians and policymakers should carefully assess their current recommendations for NSAID use and adhere to a more unified consensus-based strategy for multidisciplinary pain management in elite athletes. In the future, we hope to see more rigorous, prospective studies of various pain management strategies in elite athletes, thus enabling a shift from consensus-based recommendations to evidence-based recommendations.

IOC consensus statement: dietary supplements and the high-performance athlete.

Nutrition usually makes a small but potentially valuable contribution to successful performance in elite athletes, and dietary supplements can make a minor contribution to this nutrition programme. Nonetheless, supplement use is widespread at all levels of sport. Products described as supplements target different issues, including (1) the management of micronutrient deficiencies, (2) supply of convenient forms of energy and macronutrients, and (3) provision of direct benefits to performance or (4) indirect benefits such as supporting intense training regimens. The appropriate use of some supplements can benefit the athlete, but others may harm the athlete's health, performance, and/or livelihood and reputation (if an antidoping rule violation results). A complete nutritional assessment should be undertaken before decisions regarding supplement use are made. Supplements claiming to directly or indirectly enhance performance are typically the largest group of products marketed to athletes, but only a few (including caffeine, creatine, specific buffering agents and nitrate) have good evidence of benefits. However, responses are affected by the scenario of use and may vary widely between individuals because of factors that include genetics, the microbiome and habitual diet. Supplements intended to enhance performance should be thoroughly trialled in training or simulated competition before being used in competition. Inadvertent ingestion of substances prohibited under the antidoping codes that govern elite sport is a known risk of taking some supplements. Protection of the athlete's health and awareness of the potential for harm must be paramount; expert professional opinion and assistance is strongly advised before an athlete embarks on supplement use.

IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete.

Nutrition usually makes a small but potentially valuable contribution to successful performance in elite athletes, and dietary supplements can make a minor contribution to this nutrition program. Nonetheless, supplement use is widespread at all levels of sport. Products described as supplements target different issues, including the management of micronutrient deficiencies, supply of convenient forms of energy and macronutrients, and provision of direct benefits to performance or indirect benefits such as supporting intense training regimens. The appropriate use of some supplements can offer benefits to the athlete, but others may be harmful to the athlete's health, performance, and/or livelihood and reputation if an anti-doping rule violation results. A complete nutritional assessment should be undertaken before decisions regarding supplement use are made. Supplements claiming to directly or indirectly enhance performance are typically the largest group of products marketed to athletes, but only a few (including caffeine, creatine, specific buffering agents and nitrate) have good evidence of benefits. However, responses are affected by the scenario of use and may vary widely between individuals because of factors that include genetics, the microbiome, and habitual diet. Supplements intended to enhance performance should be thoroughly trialed in training or simulated competition before implementation in competition. Inadvertent ingestion of substances prohibited under the anti-doping codes that govern elite sport is a known risk of taking some supplements. Protection of the athlete's health and awareness of the potential for harm must be paramount, and expert professional opinion and assistance is strongly advised before embarking on supplement use.