UFC middleweight Elias Theodorou penned a fantastic open letter about his struggles to get a therapeutic use exemption (TUE) for cannabis from the UFC’s anti-doping partner, USADA. In it, he details how cannabis is the best treatment option for his issue, neuropathic pain in his wrists and elbows. USADA’s own TUE guidelines recognize that cannabis is an effective and common treatment for neuropathic pain.

That doesn’t make it a simple matter to get a TUE, though. Elias has been working to get a TUE for a year-and-a-half, and is hopeful his latest application ahead of his December 8th bout against Eryk Anders will be the one to finally succeed.

One of the issues is USADA’s guidelines essentially require a fighter to exhaust non-prohibited methods and show they don’t work before allowing them to use a prohibited method. In many instances this makes sense, but when it comes to pain management, things aren’t so simple.

Among the biggest problems is the classes of drugs athletes have to rule out have potentially major side effects, and some even have significant addiction potential. Theoretically athletes don’t have to try these drugs - if their physician can present a medical reason that they can’t use them, that’s enough - but in practice, most athletes won’t have an allergy or other medical issue preventing them from trying the drugs.

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Unfortunately, you usually only find out if you’re one of the people who gets major side effects from a drug by trying the drug. Your doctor saying, “This prohibited drug performs better, is safer, and has no addiction potential” isn’t usually enough for USADA. You have to actually try the less safe drugs first.

The classes of drug USADA says should be tried for neuropathic pain are:

1) Antidepressants such as tricyclic amines (e.g., amitriptyline, nortriptyline) and dual reuptake inhibitors of serotonin and norepinephrine (e.g. duloxetine, venlafaxine);

2) Anticonvulsants such as gabapentin and pregabalin.

Let’s briefly examine these drugs and their potential side effects. Antidepressants, especially tricyclic antidepressants, come with a huge range of side effects. Ranging from psychological side effects like suicidal ideation to physical effects like blurred vision, weight gain or loss, low blood pressure when standing, increased heart rate, constipation, nausea, diarrhea, anxiety, impotence, seizures and more.

Gabapentin and Pregabalin aren’t much better. Elias details his issues with these in his open letter, with issues like weight gain, constipation and other gastrointestinal issues happening to him. These aren’t the sort of issues a fighter who has to train daily and make weight can just shrug off. Other potential side effects include headaches, mood changes, swelling of the limbs, sleepiness, blurred vision, impotence and more. These are not minor issues, but athletes are expected to try these drugs!

Other recommended therapies include the powerful and addictive opioid class painkiller, Tramadol. Tramadol is currently on the WADA monitoring list for 2019 due to its apparent use to enhance performance in sports like cycling. Despite this, USADA’s current TUE rules would prefer athletes use this addictive narcotic instead of cannabis. This is despite the current, well-documented, ongoing opioid crisis in both the United States and Canada.

Cannabis being prohibited in the first place is a decision which makes little sense. No other drug with similar effects is treated the same way, and its inclusion is clearly a political rather than science-based decision, as I discussed in depth earlier this year.

There are several potential solutions.

WADA itself could remove cannabinoids from the prohibited list. This is unlikely, with the organization currently struggling under the weight of its own dysfunction, with even USADA regularly attacking the anti-doping agency. The UFC could remove cannabinoids from the prohibited list it uses. It is not a signatory to the WADA code and it could simply inform USADA that cannabinoids are no longer consider prohibited substances in the UFC. USADA would stop testing for it and the problem is solved. So far, there seems to be little to no political will in the UFC for making that happen, and it wouldn’t solve the issue of athletic commissions still banning cannabinoids. The UFC could modify its rules on TUEs to make it easier to gain a TUE for cannabinoids. The UFC’s TUE policy already differs from the policy USADA uses for Olympic athletes in some important ways. For instance, Cris Cyborg would not have qualified for a retroactive TUE for her use of spironolactone as she failed to disclose she was using it until she was caught. Under the WADA code, that rules out a TUE. The UFC code allows athletes who didn’t declare a substance to still apply for, and gain, a TUE. WADA could also potentially modify its rules and guidelines for getting a TUE for cannabis, which would have a knock-on effect on USADA’s guidelines. Again, that seems unlikely due to the organization’s well-publicized and ongoing problems with its governance.

Until one of those things happens, athletes like Elias Theodorou are left in the lurch, having to pop pills that have horrible side effects on them just to eventually, hopefully, be allowed to take a safe, well-tolerated drug that works for them. It shouldn’t take a year-and-a-half for an athlete to be allowed to fix a medical problem, especially when that fix doesn’t involve a drug that has any significant potential to enhance performance.

A TUE is required when an athlete wishes to take a drug that is on the prohibited list. In this case, cannabinoids are only prohibited in-competition, but the test used to detect THC is able to detect use for days to weeks beforehand, depending on how much a person uses. That means even if Elias didn’t want or plan to use cannabis on fight day, and thus wouldn’t even be under its effects when he fought, he would still need a TUE to be safe.

Despite the long process, Theodorou has made it clear that he feels USADA have been helping him navigate the TUE process and credits them with the advice and assistance they have given him as he attempts to gain a TUE for his medical problem. The issue isn’t with individuals; it’s with outdated and arguably unsafe rules.