Therapeutic use exemptions in sport: Medical cannabis

“I want to be a famous footballer when I grow up” or “I’m going to be in the Olympics one day” are phrases children use every single day, all around the world.

For many, sport isn’t just a hobby, it's a passion, a purpose, and a lifelong goal. The love of the game, the thrill of competition, and the dream of becoming a household name are powerful motivators after all. 

And if you’re reading this blog, there’s a good chance that you’ve made this childhood dream become a reality. So, firstly, well done!

But, should your healthcare choices impact your ability to live out your dream, or stand in the way of your athletic career? Absolutely not - and that’s why Therapeutic Use Exemptions (TUEs) exist, but be warned, the process isn’t always straightforward. 

In this blog we’ll give a rundown of what TUEs are, why they matter, and how you can secure one. 

Can professional athletes use medical cannabis?

Yes.

Any adult in the UK who has a diagnosed health condition that is known to respond to cannabis-based treatments can explore medical cannabis, providing:

• They are not pregnant
• They are not breastfeeding
• They do not have a history of psychosis or schizophrenia
• Traditional, first-line treatments for their condition have been proven to be ineffective, unable to meet their needs, or, have caused them to endure unpleasant side effects. 

Is medical cannabis banned in sport?

According to Global DRO, medical cannabis, and delta-9 tetrahydrocannabinol - or THC - is listed as prohibited during competition, but not outside of competition, for sports such as rugby, football, cricket, boxing, diving, and cycling. 

This means unless you have Therapeutic Use Exemption you cannot use these substances during competition periods, and if you do, consequences are likely to occur. These can vary depending on the sport, the competition level, and the regulatory board who oversee it, but will almost always result in an Anti-Doping Rule Violation and a sanction. 

If you compete in a sport we’ve not listed, use Global DRO to check the prohibition status of medical cannabis, both in and out of competition, to find out if you need to apply for a TUE.

The World Anti Doping Agency (WADA) prohibited list

We’ve previously spoken about The World Anti Doping Agency on our blog in content centred around cricket, but if you haven’t read this post - here’s a quick summary:

What is WADA?

The World Anti Doping Agency was co-founded by 140 different governments in 1999 to independently establish and coordinate anti-doping rules and guidelines across all nations, for all sports. 

WADA determine which substances, and administration methods, are banned, or prohibited during sports, and provide the framework athletes can use to apply for a TUE should their medication fall into prohibited categories. This prohibited substance list is updated and reviewed on the 1st of January every year. 

Global DRO is a handy website that filters through sports and substances to provide the latest classifications enforced by WADA. 

What is the difference between WADA and UKAD?

UK anti-doping (UKAD) oversees anti-doping policy here in the UK, ensuring that national sporting competitions, organisations, and athletes comply with codes established by WADA. 

Is cannabis prohibited by WADA / UKAD?

WADA’s prohibited list, splits substances - and administration methods - into three categories: 

1. Those that are prohibited at all times
2. Those prohibited only within particular sports
3. Those prohibited in competition periods. 

In competition, medical cannabis, and THC in particular, are specified substances that are prohibited by WADA, and therefore, the UKAD. 

The prohibited substance list states: 

“In competition all natural and synthetic cannabinoids are prohibited, e.g:
• In cannabis (hashish, marijuana) and cannabis products
• Natural and synthetic tetrahydrocannabinols (THCs)
• Synthetic cannabinoids that mimic the effects of THC.”

There is one exception: pure cannabidiol - or CBD.

However, athletes using cannabis-based treatments that contain THC, such as prescribed cannabis oil, medical cannabis flower, and therapeutic THC vapes, can apply for a Therapeutic Use Exemption.

What does ‘in competition’ actually mean?

Typically, ‘in-competition’ starts at 23:59 the day before a competition, and spans right through to the end of the competition period and any sample collection processes. This relates to all competitions overseen by WADA, from large-scale national events like the Olympics and Paralympic Games, to lesser known competitions such as those held by the World Air Sports Federation and the World Underwater Federation.

However, it’s important to note that while you may not have taken medical cannabis during competition periods - cannabinoids will still be present in your system if you are routinely prescribed medical cannabis, and if you don’t have a TUE, it’s highly likely that sanctions would be enforced if this is detected. 

Which leads us on to our next section:

Therapeutic Use Exemptions: Everything you need to know

Therapeutic Use Exemptions allow athletes to use otherwise prohibited substances - or administration methods - during competitive events. 

In order to apply for a Therapeutic Use Exemption, athletes must have a diagnosed medical condition that the prohibited substance is prescribed to treat, manage, or support, and be able to evidence this using medical documentation. 

A Physician Guideline and Checklist is provided by WADA to explain the qualifying criteria for TUEs, and it's recommended that both athletes, and their doctor, read this thoroughly before submitting a TUE application to the relevant ADO (anti-doping organisation).

The International Standard for Therapeutic Use Exemptions guidelines state:

“[TUEs] does not consider whether the prohibited substance or method is the most clinically appropriate or safe, or whether its use is legal in all jurisdictions. 

For example, the use of narcotic analgesics and cannabinoids may be acceptable from a medical and TUE perspective, but the relevant sporting association may decide that, in certain situations, the use of narcotics and cannabinoids are an unacceptable safety risk to the athlete and/or other competitors….

It is important to note that anti-doping authorities are not agents for law enforcement and do not carry the authority to grant athletes legal right to possess and carry illegal and/or controlled substances, such as narcotics and cannabinoids (and rarely some stimulants) across jurisdictional or international borders. It is the responsibility of the athlete to be aware of the law in the countries or jurisdictions in which they may be travelling.”

How do I find out if medical cannabis is legal in the country I am competing in?

If you’re a Releaf patient, in the resource section of your patient dashboard you can find specific guidance and advice for travelling with medical cannabis. This includes instructions on how to apply for a travel certificate from Releaf, and how to carry your medication when travelling abroad. 

If you are not a Releaf patient yet - don’t worry - this information is also available in our dedicated education section: Travelling with medical cannabis. Here, we give an overview of which countries have legalised cannabis-based medications and treatments, and outline the necessary requirements before travelling with prescribed cannabis treatments, such as getting approval from the embassy of the country you plan on visiting, and advice on how to contact the airline, or transport provider, to make them aware of your plans.

How to apply for a TUE for medical cannabis

The first thing to emphasise is preparation is key, and the earlier you apply for a TUE, the better.

For substances prohibited in competition only, it's recommended that Therapeutic Use Exemption applications should be submitted at least thirty days before the competition starts. The only exception to this rule is if this substance has been prescribed in an emergency or exceptional situation, which is highly unlikely to be the case when it comes to medical cannabis, as it is not prescribed as a first-line treatment here in the UK. 

Along with the application itself, a comprehensive medical history that contains documentation from the doctor who diagnosed the condition you’re using medical cannabis for, as well as the results of any relevant scans, imaging studies, or laboratory investigations should be submitted. Your doctors' signature is also required on the TUE application, and we’d also recommend submitting a letter from the clinic who supplies your cannabis-based medication to provide supporting evidence of why this treatment was sought out, and ultimately, prescribed to help manage your symptoms. 

TUE applications are submitted to the anti-doping organisation (ADO) that oversees the competition through the Anti-Doping Administration and Management System (ADAMS) unless otherwise stated by the relevant ADO. Applications are then considered by the TUEC (Therapeutic Use Exemption Committee) and either approved, or denied within 21 days of receiving the application.

The TUEC also decide the specified duration for Therapeutic Use Exemptions, and they automatically expire at the end of this period. It’s worth noting that TUEs only cover the competition they were requested for, and if you are competing in another competition, a new TUE must be submitted, and if you’re involved in a sport that has competitive seasons, we’d advise ensuring this is done well in advance of the first TUEs expiry date. 

How do the TEUC decide if a TUE should be granted?

According to the International Standard for TUEs, an athlete may be granted a TUE if they can prove, on the balance of probabilities, that:

1. The prohibited substance or prohibited method in question is needed to treat a diagnosed medical condition, and this is supported by relevant clinical evidence.
2. Said substance or administration method will not enhance performance beyond the athlete's “normal state of health”. It’s assumed this means the athlete's state of health prior to requiring the prohibited substance to treat a specific health condition.
3. There is no reasonably permitted therapeutic alternative to the prohibited substance or administration method for said athlete, and it is an indicated treatment for their diagnosed medical condition. 
4. The prohibited substance or method of administration is not required as a consequence of previously using a substance (or administration method) that was also prohibited by WADA. 

Final thoughts: Your health, your sport, your choice

Managing a chronic health condition can be hard enough, let alone when you’re competing in professional sport and have questions about whether you’ll be penalised for your healthcare choices. 

At Releaf, we believe that your choice of treatment shouldn’t impact your career, and with the right support, proper preparation, and a successful TUE - you shouldn’t have to choose. Our clinical team can assist you in providing the necessary documentation needed to substantiate your Therapeutic Use Exemption application, and support you throughout this process. 

If you’ve not started your medical cannabis journey yet, perhaps because medical cannabis does sit on WADAs prohibited substance list, speak to one of our specialist doctors for individualised advice, support, and guidance on how to take the next steps. 

Our sign-up process is fast and free and can give you an indication in under a minute whether medical cannabis may be the solution you’ve been searching for. 

What have you got to lose? Let’s rethink healthcare.