Editor's note: This article appeared earlier on VeloNews.com,but an off-the-cuff comment regarding new standards for caffeine and pseudoephedrinecreated some level of confusion. We have since checked with USADA and USACycling and feel comfortable with the original information included inthis column.

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At this year's training camp for the Health Net/ Maxxis team, riders andstaff hit me with an assortment of questions covering a wide range of medicaland scientific topics. The subject of recent changes in anti-doping regulationscame up repeatedly.“Why is the US government making ephedrine illegal while the World Anti-DopingAgency (WADA) is making it legal?!” one rider asked.Of course the answer is that ephedrine is being removed from productsin the US due to deaths associated with its use, while pseudoephedrinehas been deemed legal by WADA.That question serves as a good starting point for a review of the recentchanges. Areas for confusion are numerous... I have to admit (with a littleembarrassment) discovering that I too had some questions about the subtletiesof the recent changes.I’d like to say right here at the start that readers should please emailwith any question or concerns they may have about my interpretation ofall this. This whole thing is definitely confusing and, as we all know,ignorance is not a valid defense once you test positive.AREAS FOR CONFUSION
Differing Lists:  WADA v. UCI
The first area where one can get started on being confused about allthis is the fact that WADA has one anti-doping list while the Union CyclisteInternationale (UCI) has another. Until Dick Pound (WADA) and Hein Verbruggen(UCI) finally end their feud, this will likely continue to be the case.Sanctions are the sticking point now and I won't even try to cover thattopic here. The UCI has until August 13, 2004 (the start of the 2004 SummerOlympic Games) to get on board. Then there's the U.S. Anti-Doping Agency(USADA), which follows the direction of individual international governingbodies. In the case of cycling, it still uses the UCI's list.WADA likes to talk about "harmonization" of anti-doping regulations.The chorus is still a bit off-key, but the situation is definitely improving.Since an athlete can be tested by any of the anti-doping agencies, my recommendationswill be based on the combined strictest interpretation of the WADA andUCI lists, i.e. if the UCI says drug X (no pun intended) is not okay whileWADA says it's okay, in my book it is not okay  and vice versa. Asa result, these recommendations are intended for cyclists specifically.Keep in mind that under WADA's World Anti-Doping Code, a substance isbanned if it meets two of the three following criteria:
• The product is performance-enhancing
• It is harmful to the athlete's health
• It is contrary to the spirit of sportIn or out?
Another area for confusion is the new distinction between "in-competition"and "out-of-competition" testing lists. For example, some substances areokay out-of-competition but illegal during  competition. (To see USADA'sdistinction between in-competition and out-of-competition tests, checkthe back side of the organization's wallet card "WalletCard: Examples of Allowed and Prohibited Substances") I prefer to simplifythis and make no distinction at all. I recommend that if something is illegalin competition, it shouldn't be used out-of-competition either.A substance by any other name...
A third aspect of all this that is fraught with confusion is the namingof substances. The ephedrine/pseudoephedrine example above is classic.These are two drugs with very similar names, very different effects onthe body, and very different regulations concerning their use. Drugs oftenhave a generic name and a trade name, e.g. pseudoephedrine is "Sudafed"in the U.S. Add to this that some drugs have different names in differentcountries and not just due to language differences. Take acetaminophen,for example. It is marketed as Tylenol in the U.S., Paracetamol in theU.K. and Panadol in France.TUEs:  “Therapeutic Use Exemptions”
Also confusing is that some substances are banned, but their use isallowed under certain circumstances and under certain conditions. Asthmainhalers are the best example (more below). These drugs can be usedif medically justified and an "Abbreviated Therapeutic Use Exemption" formis submitted.Below okay, Above NOT okay
There are also a host of substances that are legal below certain thresholdlevels or ratios, but banned when those levels are exceeded. I like tothink of all these as simply banned completely because it is so difficult(usually impossible) to predict what amount of use will still test belowthe cut-off levels.“Related Compounds”
Finally there is the whole "related compounds" topic in which WADAand the UCI both recognize the impossibility to specifically list every conceivable substance. WADA refers to these as "other substances with similarchemical structure or similar pharmacological effects." The recent THGand Modafinil controversies in Track and Field demonstrate this problemnicely.CHANGES FOR 2004
Local Anesthetics
Under WADA's code - not yet adopted by the UCI - local anestheticscan now being used without any restrictions. An abbreviated TUE form isno longer required. This is the "-caine" family of drugs such as Lidocaine(Xylocaine) that your dentist may inject during dental work or that maybe contained in "Lidocaine jelly" which is sometimes applied to road rashbefore cleaning the wound. An important exception here is that while cocaineis very much a member of this family of drugs, it remains very much illegal.Caffeine and Pseudoephedrine
Under WADA rules, these two are now allowed in any form and at anyblood or urine level. Hey, maybe we'll see the reappearance of those 5-and 10-gram caffeine rectal suppositories from south of the border! I don'tpersonally think allowing unlimited levels of either of these was a gooddecision.Some substance similar to caffeine and Pseudoephedrine are subject tospecific cut-off levels: Cathine (Norpseudoephedrine) 5 micrograms/ml,Ephedrine and Methylephedrine 10 micrograms/ml, and Phenylpropanolamine25 micrograms/ml. Again, since it's difficult or impossible to predictwhat level of use of these substances will still result in a legal level,I strongly recommend you just consider these four completely banned.Corticosteroids
The use of Corticosteroids is still strictly controlled. Non-systemicuse (inhalers, creams, eyedrops, subcutaneous injections, and injectionsinto a joint) still require an abbreviated TUE. WADA still considers thesystemic use (intravenous or intramuscular injections, oral, rectal) forbidden.The UCI however now allows for systemic use of Corticosteroids in emergencysituations if a very precise paperwork process is followed. This paperworkcan be done even after the fact if the medical situation justifies theimmediate use of systemic Corticosteroids. I can think of no situationother than a severe allergic reaction that would qualify for this exemption.Call this the "JonathonVaughters rule."Asthma Medications
The usual list of asthma inhalers are still allowed and still requirean abbreviated TUE. It's quite interesting to see that the UCI has nowdecided to agree with WADA and adopt the 1000 ng/ml cut-off level for Salbutamol(Albuterol, Ventolin). This was the source of a great deal of controversyduring the 2002 Tour de France when ONCE rider IgorGonzalez Degaldeano scored an off-the-charts 1360 ng/ml on this onewhile wearing the yellow jersey. WADA considered this a positive, but theUCI considered him negative (oh the magic of the maillot jaune).This was one incident (though not the first) that put WADA and the UCI at odds.Anabolic Steroids
The UCI now allows for a Nandrolone cut-off level of 5 nanograms/ml.For a level between 2-5, they can require an "endocrine evaluation." Theregulations also describe cut-off levels and ratios for other anabolicsalong with the "endocrine evaluation" possibility and a "retrospectiveanalysis of previous results" option. Suffice it to say that anabolic steroidsare illegal. And in case anyone out there hasn't heard yet, supplementsmay be spiked with anabolic steroids (and cigarette smoking has been associatedwith lung cancer and emphysema).Masking Agents
The UCI regulations are now more precise about the use of masking agents.Again this seems to be a reaction to a specific problem that arose thispast season. Bromantan, Probenecid, Epitestosterone, and diuretics (a listof these is included) are specifically listedGene Doping
WADA regulations now forbid this practice stating that "gene or celldoping is defined as the non-therapeutic use of genes, genetic elementsand/or cells that have the capacity to enhance athletic performance."The UCI regulations don't make any comment about gene doping so I guessall the cycling teams' Team Geneticist jobs are safe for now.WADA'S "Specified substances" list
WADA has a list of substances they refer to as "Specified Substances."They are all banned but get special mention because they "are susceptibleto unintentional anti-doping rule violations because of their general availabilityin medicinal products or which are less likely to be successfully abusedas doping agents. A doping violation involving such substance may resultin a reduced sanction as noted in the Code provided that the athlete canestablish that the use of such a specified substance was not intended toenhance sport performance...." Curious.WADA's "2004 Monitoring program"
WADA also lists some substances that "are not on the Prohibited List,but which WADA wishes to monitor in order to detect patterns of misusein sport." Curiouser.
These deserve listing here: caffeine, phenylephrine, phenylpropanolamine,pipradrol, pseudoephedrine, synephrine, morphine/codeine ratio.Marijuana
I'm amused to see that WADA bans marijuana for all sports while theUCI list only considers it illegal only for downhill mountain bikers.Anyway, since WADA considers pot banned, so should you.FINAL RECOMMENDATIONS
If you have any doubts whatsoever about the legality of a drug, contactthe USADA Drug Reference Line at 1/800-233-0393 or drugreference@usantidoping.org.Don't forget to mention that you are a cyclist and that for now your internationalfederation the UCI has a different list than WADA.If you a required to give a urine and/or blood sample for anti-doping,be absolutely meticulous about listing anything you've taken in the lastmonth or two. I recommend keeping a personal log. Don't leave anythingout. Please note, however, that simply listing something does not meanthat you have met the requirements of the abbreviated or full TUE.If you receive notification of a non-negative A sample, contact yourteam management immediately. Currently only the athlete, the USOC and hisnational federation are notified by the anti-doping agencies. You owe itto your team management to get them involved. Do it immediately, as someof your options expire only three days after your notification.INFORMATION SOURCES
USADA just made available "TheUSADA Guide to Prohibited Classes of Substances and Prohibited Methodsof Doping." It is absolutely a must read for athletes subject to anti-dopingtesting. It's 68 pages long, but nicely done and very readable.USADA's "WalletCard: Examples of Allowed and Prohibited Substances" is pretty good
UCI's "ProhibitedClasses of Substance and Prohibited Methods":
WADA's "2004Prohibited List"

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Dr. Prentice Steffen, board certified in both emergencymedicine and sports medicine, is serving as team doctor for the HealthNet Pro Cycling Team Presented by Maxxis and  the TIAA-CREF Presentedby 5280  Magazine Development Cycling Team. He has served as teamdoctor for several teams including Prime Alliance, Mercury, Spago and U.S.Postal. Steffen has also served as medical director and event physicianfor major races including the Tour Du Pont, New York City Marathon andthe Tour de Trump. Steffen also serves as the sports medicine section editorfor the Journal of Emergency Medicine. His services are outlined in detailat www.pdssportsmed.com.Please send your sports-related medical questions to"Ask the Doctor" in care of WebLetters@7Dogs.com.We will forward a selection of questions to one of three physicians currentlyworking with this site.Important Notice:
The information provided in the ASK THE DOCTOR columndoes not constitute formal medical advice. The information provided onthis public web site is provided solely for general interest of the visitorsto the site. The information contained in this column applies to generalmedical practice and may not reflect current medical developments or beinterpreted as medical advice. Understand that reading the informationcontained in this column does not mean that you have established a doctor-patientrelationship with Dr. Prentice Steffen. Readers of this column should notact upon any information contained in the web site without first seekingmedical advice from their personal physician.