Cannabis in Sports: Unpacking Exemptions for Therapeutic Use

boxing MMA sports
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For most adult Canadians, cannabis has never been easier to access. Meanwhile, our elite athletes must abstain while they are in competition or face aggressive fines or suspension.

Canadian MMA fighter, Elias Theodorou, suffers from bilateral neuropathic pain. He feels the pain from his condition in his upper extremities—his hands, wrists, and elbows are all affected.

When he fights, he says, the locations of these “flare-ups” come in direct contact with whatever he punches, elbows, and blocks. “Every time I punch there’s a shocking pain, it’s almost like a stinger.”

Sometimes Theodorou can’t feel these areas of his upper extremities and will push his training to the point of near-injury without realizing. This sort of overexertion could put any athlete into the danger zone.

Theodorou would like to add medical cannabis to his medicinal toolbox, but the rules set out by more than one anti-doping group bans cannabis in his sport.

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Despite having a recommendation for medical cannabis from his long-time family doctor, Theodorou has been unsuccessful at securing a medical exemption from the US Anti-Doping Agency (USADA), which administers the UFC’s anti-doping program.

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Theodorou has been training in mixed martial arts for the better part of a decade and fighting professionally for nearly six years, but some of the pain he feels today can be traced back to an adolescence spent skateboarding. He has arthritis in his wrists, likely due to a series of breaks and fractures sustained while skateboarding.

The aftermath of that damage leaves him with limited range of motion, and it has even forced him to change his fighting style. His access to medical marijuana in Canada helps, he says, but he must abstain for up to six weeks before a fight if he wants THC to be flushed from his body—the only way he can use cannabis and still qualify for his fights.

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Fighters in the UFC are not tested for cannabis out of competition, as per the World Anti-Doping Agency code. But THC, the primary psychoactive compound in cannabis, is prohibited in the days leading up to the fight. If THC is detected in a fighter’s system close enough to the match—at the weigh-in, for example—they will face consequences.

Canada has a separate athletic organization that monitors athletes for potential doping. For both organizations, it is standard, under the World Anti-Doping Code, that they follow World Anti-Doping Agency (WADA) rules.

The Canadian Centre for Ethics in Sport (CCES) has several working groups and committees overseeing things like banned substance testing and issuing Therapeutic Use Exemptions (TUE) for banned substances, like cannabis.

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Canadian athletes need to be careful not to confuse legalization of cannabis in Canada with permission to use cannabis in sport.
Canadian Centre for Ethics in Sports
The organization has—for years, they tell Leafly by email—recommended that cannabis be removed from the WADA Prohibited List because they do not believe it meets the standards to be included in the list.

“The CCES has in the past recommended to the WADA List Committee that cannabis [is] removed from the Prohibited List as we feel the evidence supporting its performance-enhancing properties is not conclusively supported by the scientific literature,” writes Paul Melia, CCES President and CEO in an email.

“The WADA List Committee has not followed our recommendation, and so cannabis use remains prohibited in sport. Therefore, even though cannabis was recently legalized in Canada, this does not affect the status of cannabis as a banned substance in sport.

“Canadian athletes need to be careful not to confuse legalization of cannabis in Canada with permission to use cannabis in sport. Canadian athletes also need to be aware that a positive test for cannabis use in competition may result in a significant sanction.”

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A TUE application will be considered by the CCES if: “The use of the prohibited substance or method would produce no additional enhancement of performance other than that which might be anticipated by a return to a state of normal health following the treatment of a legitimate medical condition;” and, if “There are no reasonable therapeutic alternatives or other alternatives are ineffective.”

To apply for a TUE with either USADA or the CCES, extensive documentation of the athlete’s medical condition, assessments from several physicians, and proof that the athlete has explored to exhaustion all non-prohibited alternatives to prohibited medications is required.

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Conventional prescription drugs, says Theodorou, don’t adequately address the sharp stinging pain and radiating heat he feels in his elbows and hands. As the intensity and frequency of his training ramps up before a fight, sometimes going five hours each day, he wishes more to have the option of using cannabis.

The irony of them telling me not to get hooked on opioids while telling me you need to try a lot more opioids before we can give you cannabis.
Elias Theodorou, Canadian MMA fighter
Despite his doctor’s recommendation, the legality of cannabis in Canada, and the legitimacy of his condition, Theodorou says he’s fighting an uphill battle with the USADA, an organization that receives funding from the Office of National Drug Control Policy (ONDCP), a US agency that must abide by the federal cannabis laws.

Without a TUE, Theodorou must rely on opioid painkillers six weeks before a fight, and laughs good-humouredly at “the irony of them telling me not to get hooked on opioids while telling me you need to try a lot more opioids before we can give you cannabis.”

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Theodorou has made four attempts at a TUE from USADA, but they need him to exercise and exhaust all options of what they call “first-line medications,” which include the traditional antidepressants, opioids, and other medications that make up his pain management drug regimen.

“They never say no,” he says, describing the responses from USADA he receives by mail. “They just say you’re denied and we need more explanation.”

Both CCES and USADA are silent about whether any TUEs at all have been issued to athletes for the use of medical cannabis, but Theodorou isn’t giving up hope.

Beyond taking steps to further pursue his own TUE, he is watching the United States for changes to the nation’s federal laws regarding cannabis and whether that, in turn, encourages CCES to grant more (if any) TUEs in Canada.