Not only do I have heart failure, but I am banned from participating in some Olympic sports!

Why does it always seem that something becomes more enticing when you can’t have it?  I must admit that other than liking to work out in the fitness center and attempting yoga, I have never been much of an athlete.  I never had dreams of competing in an Olympic activity (unless they have added an event for clothes shopping).  So why was I disappointed in February when I learned that I might be banned from ever competing in some Olympic sports?

Just what is the basis of the potential ban you ask?  Is there a lifetime ban on clumsy people?  Does my heart device give me an unfair advantage?  Close but it is not the device that gives me an edge.  No, those blasted beta blockers are the culprit.  
​

 Yep – if you look at the list of drugs banned by the World Anti-Doping Agency, you will see that both carvedilol (which I was on for approximately five years) and bisoprolol (which I am currently on) are on the list of prohibited beta blockers.  The ban says : ” Beta blockers are prohibited during competition in a number of sports; out of competition, they are prohibited only in archery and shooting.”

Well, you say, there is a loophole that says that they are only totally prohibited in two sports.  The prohibition for the other sports is just during the competition (although I am not sure how the word “competition” is defined – the day of the competition, or the week before the competition, or some other time frame).  Sure, I guess I could ask my doctors if they could approve going off the beta blockers for a period of time so I could compete.  I’m sure they would roll their eyes, wondering if I had lost my mind.

But then I did the lawyer thing.  No, I didn’t read the fine print – but almost.  Instead, I read the footnotes.  And the footnotes said that there are therapeutic use exemptions to denote banned substances athletes may be "required to take to treat an illness or condition".  The particular exemption that applies to me is the therapeutic use of beta blockers in athletes.  So the exemption gives me hope that I could be a contender should I ever find the energy and time to take up Olympic archery.  (Of course, given the tendency of heart failure patients to have shortness of breath, I suspect that holding up a bow and keeping it steady to aim the arrow would be beyond my capabilities.  But I can dream).

The reason that I even know what is on the list of drugs that are banned is that I saw several stories regarding a former bronze medal winner at the 2018 Winter Olympics.  He lost his medal for taking a substance that was on the list.  He was a Russian curler who took the beta blocker drug known as meldonium.

Then I began to overthink this, which is how some of my blog posts are born.  Why would anyone take a drug that they are not medically required to take?  I mean, I am medically required to take a beta blocker but I cannot say that I am thrilled about it.  Some of the impacts have been wearing, especially having to learn how to navigate the side effects of dizziness and fatigue.  While I realize the drug benefits my heart, I dream that there may be a day where my heart is strong enough to go off these drugs.  I suspect that will never happen.

So why are there people taking beta blockers voluntarily for something other than a medical reason?  According to an August 1, 2016 story on the Washington Post website:  “These drugs lower blood pressure and heart rate and generally make people less jittery. They are banned in Olympic sports that require steady hands: archery, shooting (including modern pentathlon) and golf.”  I am assuming that the reason for the ban is that the beta blocker provides a competitive advantage. But perhaps the lure of a medal, and the subsequent endorsement deals, may be what triggers an athlete's decision to take a banned drug.

Imagine my surprise when I found that it is not only athletes who are seeking benefits from beta blockers for performance purposes.  I found an October 4, 2004 New York Times article entitled Better Playing Through Chemistry.  The article advised that classical musicians used beta blockers to manage performance anxiety.  I’m not making this up, as you will see from the following quotation from the article:    

• “The little secret in the classical music world -- dirty or not -- is that the drugs have become nearly ubiquitous. So ubiquitous, in fact, that their use is starting to become a source of worry. Are the drugs a godsend or a crutch? Is there something artificial about the music they help produce? Isn't anxiety a natural part of performance? And could classical music someday join the Olympics and other athletic organizations in scandals involving performance-enhancing drugs?   

The article quoted a doctor who said:  "I believe beta blockers are far more beneficial than deleterious and have no qualms about prescribing them."  However some musicians had begun to have some reservations about this practice.  They were concerned that the drugs were often being used without medical supervision.  One doctor said that beta blockers should be obtained only after a medical examination, since people with asthma or heart disease could develop problems like shortness of breath or a slowing of the heart rate. 

Are these concerns valid?  Even though some of the drugs I take may have side effects, the federal Food and Drug Administration (FDA) has a rigorous and lengthy process to approve the use of a drug for particular purposes.  The labeling on the drug container, and accompanying package inserts, will include data developed as part of the process.  This will include tips for when to take the drug, whether to take it with food, the risks of using the drug, and information doctors should discuss with patients before they take a drug.  But what if you are a musician or athlete taking them for the reasons discussed above.  Has anyone considered the impact that stems from such uses?

Some of you may ask:  Isn’t it true that doctors sometimes prescribe a drug for an “off label” purpose?  In other words, your doctor suggests using an FDA-approved drug for an unapproved use to treat your disease or medical condition. 

The FDA has an article on their website about off-label prescriptions.  In the section entitled “Why might an approved drug be used for an unapproved use”, it says: 

• From the FDA perspective, once the FDA approves a drug, healthcare providers generally may prescribe the drug for an unapproved use when they judge that it is medically appropriate for their patient. You may be asking yourself why your healthcare provider would want to prescribe a drug to treat a disease or medical condition that the drug is not approved for.  One reason is that there might not be an approved drug to treat your disease or medical condition.  Another is that you may have tried all approved treatments without seeing any benefits.  In situations like these, you and your healthcare provider may talk about using an approved drug for an unapproved use to treat your disease or medical condition.
  
  

To me, the FDA seems to be addressing scenarios that are distinct from the athlete scenario.  This is because the FDA lists a specific medical condition that needs to be addressed.  The off-label use is being carefully monitored by your health care provider.  As there is no mention of treatment exemptions in the articles I found, it appears that the athletes who have either been disqualified or lost medals used beta blockers and other drugs solely to gain a competitive advantage. 

I have heard some anecdotes that lead me to believe that the use by musicians may be a valid use.  I heard about the case of a very gifted musician who had stage fright anxiety that was so  severe it prevented her from performing at all, which was problematic since this was her livelihood.  She tried other options like anti-anxiety drugs but they were not effective or had debilitating side effects.  Her doctor decided to prescribe beta blockers and she was able to perform and earn her livelihood. 

It would seem that this woman’s use of the drug was not taken to enhance her performance.  Rather, it was used to manage a condition that would otherwise disable her performance.  As a person who has bouts of obsessive compulsive disorder, I can relate to the damage that an anxiety disorder can cause in one’s life.  So using a beta blocker to cure a disabling condition that I believe is classified by medical authorities would seem to fall into the category of off-label uses discussed by the FDA.  This performer also was well monitored by a doctor.  This should help her avoid an unintended consequence of adversely impacting her heart rhythm.      

Looking again at the uses that seem to have no medical connection - what is the potential problem with those uses?  The beta blocker basically blunts or lowers the heart rate.  The beta blocker achieves this effect by causing your heart to beat more slowly and with less force, thereby reducing blood pressure. Sure, there is a short term result of making steadying hands and nerves which likely improves performance.  But in the long run, is it possible that you are sustaining some damage to your heart. 

​As I have begun to realize, a lot of things in life are about risk management.  At the end of the day, the athletes and the musicians discussed in this article are adults.  Assuming that their use does not violate anti-doping poicies, it is not my place to tell them what to do with their lives, or whether being the best athlete or the best musician is worth the risk. 

But here is one lesson that I am beginning to learn about the concept of risk management.  I do not know if this lesson is one of age or one of being the unfortunate victim of heart failure when I was in excellent health.  But the conclusion I have come to is that once you are placed in your grave, the time for rethinking an action has definitely passed.   So we should all be deliberate and informed before we make any decision we make that impacts our bodies and our organs.