"K Bao" Valieva's free skating ended dismally: Doping and competitive sports, the never-ending cat-and-mouse game

Written by reporter Wang Xueying Edited by Liu Zhao

New Media Editor/Li Yunfeng

Interview experts

Xu Zhanming (Associate Professor of Beijing Sports University, National Anti-Doping Lecturer, International Referee)

Figure skating has always been synonymous with "beauty" at the Winter Olympics. However, at this Beijing Winter Olympics, a huge dark cloud has always shrouded this event: Recently, Russian female figure skater Kamila Valieva, known as the "genius girl", was reported to have tested positive for doping after the team competition - testers found a small amount of trimetazidine in her urine test sample from the World Championships last December.

Although Valeyeva was still allowed to participate in the individual competition afterwards, there is no doubt that this "Rashomon" caused great controversy around the world and also affected her normal performance: on February 17, in the women's free skating competition of the 2022 Beijing Winter Olympics figure skating competition, Valeyeva, who ranked first in the short program, made many mistakes and ranked fourth with 224.09 points, missing the podium.

Russian Olympic Committee athlete Kamila Valieva competes on February 7. Photo by Xinhua News Agency reporter Li Yibo

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What is trimetazidine?

In fact, this is not the first time that trimetazidine has come into the public eye: in 2014, my country's famous swimmer Sun Yang was also banned for taking this drug. People can't help but ask, what kind of drug is trimetazidine? Before answering this question, we need to understand another question: How does the human heart metabolize physiologically?

As we all know, due to long-term and extensive high-intensity training, athletes' physiological metabolic levels have always been high. For the heart that obtains blood oxygen supply through the coronary artery, each contraction requires consumption of "energy" or ATP (adenosine triphosphate), and there are generally two main ways to produce the latter, either through aerobic metabolism - synthesizing ATP through the decomposition of fatty acids, or through anaerobic metabolism - synthesizing ATP through the decomposition of glucose.

▲Oral trimetazidine medicine (Image source/Wikipedia)

In this process, the subtle role of trimetazidine is brought into play: it helps maintain energy metabolism in the heart and nerve sensory organs under ischemia and hypoxia. Specifically, trimetazidine can inhibit an enzyme that plays a vital role in the decomposition of fatty acids. Through this inhibition, the drug can further inhibit the body's aerobic metabolism and, with the help of the regulation of energy balance in the body, compensate by increasing the anaerobic metabolism of glucose. For the heart, trimetazidine can provide energy when the myocardium is ischemic and hypoxic, and this supply does not require the consumption of oxygen.

In view of these functions, trimetazidine has been used in clinical medicine to improve myocardial energy metabolism and can assist in the treatment of temporary cardiac ischemia such as angina pectoris. Studies have shown that in the clinical treatment of patients with stable angina pectoris, if trimetazidine 60 mg is administered daily, it can effectively reduce the frequency of angina attacks and the use of nitroglycerin, and improve the exercise capacity of patients with angina pectoris who cannot be adequately controlled by conventional anti-angina drugs.

Since trimetazidine can protect hypoxic cells, maintain the heart's contractile function when the heart is hypoxic, and limit rapid fluctuations in blood pressure, if athletes take it for a long time during training, it can indeed improve the hypoxia tolerance of myocardial and skeletal muscles and help athletes maintain a stable heart rate under high-intensity exercise. For this reason, trimetazidine is regarded as a highly effective heart function enhancer in competitive sports, even in the field of fitness, and this effect is particularly evident in sports that require extremely high endurance.

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No Excuse for Illegal Drugs

Some people may ask, the pharmacology of trimetazidine cannot make people "excited", right? Then is it still a stimulant? The answer is definitely yes, but it may be more accurate to call trimetazidine a "banned drug".

In fact, although the stimulants taken by early athletes to improve their performance were mostly stimulants, with the development of science and technology, the term "stimulant" in modern sports covers a wider range of categories, including not only stimulants but also inhibitory agents. However, the international community still habitually uses the term "stimulant" to refer to banned drugs.

▲Basic classification and use of stimulants (drawn by Wang Xueying, picture source: Zhihu "Cycle Disqualification")

Generally speaking, athletes use banned drugs for the following purposes: to increase muscle or bone weight and strength, to improve oxygen supply to exercised tissues, to excite and stimulate the body, to mask injuries and pain, to lose weight, to relax body tissues, or to mask the abuse of other drugs. The World Anti-Doping Agency (WADA) has also classified banned drugs according to their different pharmacological effects, and has detailed regulations on the use of different banned drugs.

However, WADA's attitude towards the characterization of trimetazidine is quite subtle. In the "Prohibited List of World Anti-Doping International Standards (2014)", WADA classified trimetazidine as a banned drug for the first time and listed it in S6 "stimulants", which is a drug that is "banned only in official competitions but can be used in daily training". In 2015, WADA upgraded the ban on trimetazidine from S6 to S4 "metabolic modulators", which is a "drug that is banned during both competitions and training."

▲In the 2022 edition of the WADA banned drug list, trimetazidine is listed in the “totally banned” category (Photo source/WADA)

People can't help but ask, how did trimetazidine upgrade from S6 banned drugs to S4 in just one year? This starts with the "effect" of trimetazidine on athletes.

First of all, trimetazidine is a "very fast-acting" ingredient: after oral administration, trimetazidine can reach the highest blood concentration in the human body within 2 hours. In addition, trimetazidine has a short half-life in the human body and can be metabolized in just 6 to 12 hours. In other words, if an athlete intends to cheat, as long as he takes the medicine according to the dosage before the game or the day before the random inspection and stops taking the medicine at the "check point", there will be no handle for illegal drug use, and he can easily take it during training and metabolize it before the game.

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A controversial choice

"Athletes are also human beings and they will get sick and catch colds in their daily lives. That's why (WADA) classifies some banned drugs as those that can be used outside of competition and those that cannot be used outside of competition," said Xu Zhanming, associate professor at Beijing Sport University, national anti-doping lecturer, and international referee. For athletes with special health treatment needs, they need to apply for the use of specific drugs and sign relevant agreements in accordance with international regulations.

"For example, pseudoephedrine, which is found in many cold medicines, is particularly effective in relieving colds, but if it must be taken during competition, there are many requirements," Xu Zhanming told reporters. In addition to common diseases such as colds, if athletes suffer from diseases such as asthma that clearly require medication, WADA will also give athletes a dosage threshold that is allowed based on treatment needs.

In the eyes of many people, the main purpose of taking banned drugs is to improve performance in competitions, so why would anyone take the risk of using them outside of competitions instead of in competitions? In this regard, Xu Zhanming said that this is actually a misunderstanding of stimulants by the public. "Banned drugs are not only used for stimulation and performance improvement, but also include those that help athletes recover quickly." He said: "They can help athletes recover quickly and increase the intensity of training, which are very important for athletes' training."

For top athletes like Kamila Valieva, who is at the peak of her physical fitness and has outstanding strength, the key question is whether it is necessary to take trimetazidine. Those who support Valieva believe that the 15-year-old Valieva not only does not need to take medicine to maintain her best condition, but also that long-term use of trimetazidine will have obvious side effects, which is not worth the loss. But outside the arena, it is undeniable that trimetazidine does help athletes increase the intensity and extend the training time in daily training, and more training is something that any athlete who wants to "achieve results" in any event in competitive sports is willing to take risks.

Image source: Tuchong Creative

"The use of trimetazidine is actually a great move because people may usually think that in order to improve performance, you usually use stimulants or other drugs that can increase heart rate and promote metabolism," Dr. Elizabeth Murray, an emergency physician at the University of Rochester Medical Center, told CNN. "But the real effect of trimetazidine is that it makes your heart work more efficiently. In theory, taking trimetazidine will not make athletes feel different, but it can improve their endurance and help athletes compete at a higher level for a longer time."

In this regard, Kelly Johnson-Aber, a medical toxicologist at the National Capital Poison Center, also believes that trimetazidine is believed to improve athletes' performance because it has a significant boosting effect on athletes' daily training. "Although it cannot achieve the muscle-enhancing or arousing effects of common stimulants, trimetazidine can improve athletes' physical fitness and endurance," she said. In many events, including figure skating, athletes' physical fitness and endurance are undoubtedly crucial in the second half of the competition.

It is understood that before being listed as a banned drug by WADA, trimetazidine was widely used by Polish athletes. Even after being included in the comprehensive banned list, it did not stop some countries from seeking to profit from it: in 2016, the Russian rowing team was directly disqualified from participating in the Rio Olympics by the International Rowing Federation because the players tested positive for trimetazidine in their urine; in 2018, Russian female bobsled athlete Nadezhda Sergeeva was forced to withdraw from the Pyeongchang Winter Olympics halfway through because her urine test sample contained trimetazidine...

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Sunshine and its shadow

Many people believe that taking banned drugs for the sake of greed is a phenomenon that has only appeared in the sports world in recent years, but the fact is just the opposite: banned drugs, competitive sports and science and technology are like shadows and sunshine. The two have an inseparable and complicated relationship that has coexisted for nearly a thousand years.

As early as 668 BC, before the advent of the modern Olympics, famous runners at the time began taking a special food to enhance their physical strength. This food was said to be made of dried figs and wet cheese. Later, people gradually discovered that taking bullwhips could also improve athletes' performance. This was the earliest behavior of humans consciously taking testosterone-type stimulants, even if the stimulants at this time were presented to humans in their most primitive form.

When the time came to the modern Olympics, doping began to appear in a more advanced form. At this stage, people did not think that taking doping was unsportsmanlike. On the contrary, many athletes took it without scruples and openly.

In 1904, British athlete Thomas Hicks crossed the finish line second in the marathon event of the St. Louis Olympics in the United States. Later, people found that Hicks' performance was inseparable from the support of stimulants - before the game, he took a stimulant liquid mixed with egg white and strychnine. During the game, when he felt exhausted, his assistant would give Hicks an injection of strychnine. At that time, strychnine was a very common stimulant because it had a certain stimulant effect on the cerebral cortex, spinal cord, etc., and this ingredient had another name in China called strychnine, which was an important ingredient in rat poison.

▲Thomas Hicks continued the game with the help of his coach (Photo source/Smithsonian)

This was the first time in the history of the modern Olympics that athletes used doping. In the nearly half a century since then, using doping to pursue better results has become one of the most common scenes in the Olympic arena. In the 1930 Tour de France bicycle race, the organizers even directly stated in the competition manual that the organizers were not responsible for paying the "drug costs" of each team. In other words, participants can use doping as needed - as long as they pay for the drugs themselves. It was not until the 1960 Rome Olympics that the consequences of crazy "drug use" began to show: Danish cyclist Knud Janssen suddenly died in the middle of the race. The cause of his death was an overdose of doping - he took too much alcohol and amphetamine before the race.

During the Cold War, some countries, such as East Germany, listed the development of high-quality stimulants as a national project. It is understood that the country once organized tens of thousands of athletes to participate in the "Komplex 08" program. From 1972 to 1988, athletes won 144 Olympic medals in one fell swoop by taking a special vitamin. Later, people found that these so-called "vitamins" were actually some kind of anabolic steroid drugs that could enhance athletes' muscle strength and increase the intensity and duration of training.

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Detection technology that is always a step behind

On the one hand, there is an endless stream of stimulant research and development driven by various interests, while on the other hand, there is the detection technology that is always "one step behind". This embarrassment has always run through the history of human anti-doping.

Faced with the increasingly crazy drug-taking behavior, the International Olympic Committee finally decided to start doping tests on athletes at the Tokyo Olympics in 1968. However, what was frustrating was that the technology at that time had no way to deal with anabolic steroids. During the entire event, the only illegal drug detected was alcohol. Norwegian athlete Hansguna Lillienwall became the first athlete in Olympic history to be checked for doping because he drank too much.

In the years since then, although people have been working hard to find ways to quickly detect doping, the devil is always one step ahead, and new stimulants have emerged too quickly. For example, erythropoietin (EPO for short) is a glycoprotein hormone secreted by the kidneys. It is often used in medicine to treat anemia. Because it can promote the production of red blood cells, it is also used in competitive sports to improve the endurance of athletes. As a commonly used stimulant, it was included in the list of banned drugs in the 20th century, but until the 2000 Sydney Olympics, people still could not find an effective detection method. Even more frustrating is that eight years later at the Beijing Olympics, German athlete Stefan Schumacher was found to have used CERA, which was used in the Tour de France, which was an upgraded product of EPO...

With the rapid development of gene technology, anti-doping has become more difficult. In this regard, Dr. Ross Tuke, a sports physiologist at the University of the Cape in South Africa, said in an interview with Nature magazine that it is not easy to detect the use of doping by athletes. "Clear drug tests during the Olympics do not mean that athletes have never used doping," he said, "because drug tests during training are very loose, but very strict during competitions, so many athletes prefer to use them during training but not during competitions." Today, with the continuous development of stem cell therapy and gene technology, doping is also becoming more "sci-fi" - Thomas Springsteen, a German track and field coach who was once known as the "perfect coach", was arrested in 2006 for trying to use gene drugs to improve athletes' performance. This gene drug called Repoxygen can theoretically stimulate red blood cells, help muscles get more oxygen, and improve athletes' endurance.

▲The artist used cartoons to satirize the impact of gene doping on competitive sports (Photo source/Alexander Turnbull Library)

Top row from left to right: runner, gymnast, javelin thrower

Bottom row from left to right: swimmers, wrestlers, TV viewers

Although there is no evidence to date that genetic doping has been used to cheat in the Olympics, it is clearly a crisis that is "at the gates" - in the foreseeable short term, the use of exogenous genes to stimulate the human body allows people to achieve the same effects as taking doping without leaving any evidence; in the crazier long term, genetic doping can "modify" part of the athlete's genes and ultimately achieve the ultimate goal of making people and events more "compatible".

"It will definitely come, we just don't know when it will come," Theodore Friedman, head of the human gene therapy program at the University of California, San Diego and consultant to the World Anti-Doping Agency, said bluntly in 2008. Eight years later, Carl Sandberg, a sports physiologist at the Karolinska Institute in Sweden, once again sounded the alarm at the European Science Open Forum, "We feel that new technologies such as gene doping may have begun to be used, although this is not easy to do, but we think it is very likely to have already appeared," he said.

If the fight over doping is like a cat-and-mouse game, then the question is: will the cat always have to chase the mouse? ■

References:

"Observation on the efficacy of trimetazidine in the treatment of stable angina pectoris in coronary heart disease". Eucommia ulmoides, Chinese Practical Medicine, 2009

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140700/

https://www.wada-ama.org/sites/default/files/resources/files/2022list_final_en.pdf

https://www.smithsonianmag.com/history/the-1904-olympic-marathon-may-have-been-the-strangest-ever-14910747/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203840/

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