What is tramadol? Explaining pro cycling's ban on the potent painkiller

On Wednesday, 17 August 2022 Nairo Quintana became the first professional cyclist to be sanctioned for using the opioid painkiller tramadol in competition. 

The case is unique in that the UCI rules, in force since March 2019, exceed those of the World Anti-Doping Agency in banning Tramadol. 

Tramadol use falls under the UCI's medical regulations, rather than its anti-doping programme, so positive tests are not treated as anti-doping rule violations. 

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Quintana has been stripped of his results from the Tour de France, where he tested positive, but has not been suspended, although he could be if he tests positive again in the future. 

The case is a novelty in professional cycling, leading to question marks and confusion, so Cyclingnews sets out all you need to know about tramadol – from its effects and its associations with performance enhancement, to the ban and what the UCI rules actually mean.

What is tramadol?

The prescription drug has been on the market since the 1970s but has only come into widespread use since the 1990s. 

It is in the class of opioids, a group of drugs that also includes powerful painkillers like morphine and oxycontin but was marketed for managing pain without the highs imparted by those drugs.

Tramadol is effective in managing low to moderate pain but it still comes with undesirable side effects that include dizziness and drowsiness, nausea and, in higher doses, respiratory issues.

Does tramadol enhance performance?

WADA added Tramadol to its Monitored List in 2012. The list typically comprises grey-area drugs or substances that might improve sporting performance. Caffeine, nicotine and the common decongestant phenylephrine are some of the other substances on this list.

There is a theory - voiced by numerous former professional riders - that the painkiller can enable a rider to push past the pain barrier and dig deeper into their physical reserves.

"It kills the pain in your legs, and you can push really hard," said former Team Sky rider Michael Barry, while Lieuwe Westra admitted tramadol was part of his use of legal methods to optimise his athletic performance. 

Performance-enhancement is not the only factor associated with tramadol; there are also health concerns. The potential for drowsiness has been highlighted as a possible cause of crashes and injuries, while it is also feared that use could lead to addiction.

What is pro cycling's history with tramadol?

The widespread use of the drug came into the public sphere after USADA investigated doping by Lance Armstrong and the US Postal Service Team in 2010.

Michael Barry, already given a six-month ban in that investigation, confessed to doping and, in 2014, told The Times that he had been given Tramadol while racing for Team Sky. Barry was on the team from 2010-2012 and retired before his ban took effect.

"Tramadol made me feel euphoric, but it’s also hard to focus. It kills the pain in your legs, and you can push really hard," Barry said. "I had nagging injuries throughout my career and I used it when I was injured and racing injured, but I also realised the side effects," he said. "It was a lot stronger than I thought and is potentially addictive."

His confessions, the UKAD investigation into British Cycling and Team Sky as well as hackers' release of Bradley Wiggins' TUEs showing legal injections of steroids before Grand Tours raised serious questions about the ethics of using grey-area drugs to help riders perform. His account of widespread use of Tramadol, sleeping pills and other grey-area substances in pro cycling was later corroborated by others. 

Former Team Sky rider Jonathan Tiernan-Locke claimed that in 2012 tramadol was offered 'freely' around the Great Britain national team. "It just didn't sit well with me," he said. "I thought, 'I'm not in any pain', why would I want a painkiller?'"

In 2018, Lieuwe Westra opened up about his use of medicines for performance-enhancement, which included tramadol. "People say: 'why do you use tramadol? [...] The answer is simple: because it is allowed and because you will perform better. And if I do not, someone else will. That's what a cyclist thinks."

How did tramadol come to be banned?

The Movement for Credible Cycling (MPCC), formed in the wake of the Armstrong case, has played an important role. Its regulations, adhered to on a voluntary basis by subscribing teams and riders, prohibit the use of tramadol and the organisation has long pushed for a total ban in cycling. 

A 2017 Monitoring Report from WADA highlighted the prevalence of tramadol in professional cycling. It showed that between 71 and 82 per cent of positive results for the painkiller came from cycling, and as much as 4% of all doping controls in cycling showed traces of the substance.

Since then, UCI president David Lappartient has pushed to ban tramadol. This proved complicated since the anti-doping regimes of sport federations typically following the WADA code, and tramadol remains on WADA's Monitored List, and not its Prohibited List. 

Even so, the UCI banned Tramadol in competition in March 2019 and immediately began testing for it.

The rules

How do they test for tramadol?

Riders may be tested for tramadol at the finish of races. Not all are, but those who are selected must report for testing within 30 minutes of the finish. 

Testing is carried out by the International Testing Agency (ITA) using a blood sample. This is typically taken from the tip of a finger using a finger-prick device, and samples are analysed using the Dried Blood Spots reference method. 

Analysis is conducted, according to the UCI, independently at a laboratory at Geneva University, using a peer review method to detect the amount of tramadol and its two main metabolites. Results are submitted to the University of Lausanne’s Anti-Doping Sciences department for review before being delivered to the UCI medical director.

Refusal to submit a sample counts as a positive test. 

What are the sanctions?

Firstly, it's important to note that tramadol does not constitute doping in the letter of the law. The regulations governing tramadol fall under the UCI's medical regulations, and not its anti-doping regulations. 

A rider who tests positive for tramadol is disqualified from the race in which the sample was collected, and stripped of results, prize money, and rankings points. They are also fined 5000 CHF and made to pay back the costs of the tramadol test. 

There is no suspension from racing for a first offence. However, bans do come into play for multiple infringements. A second positive case - on top of race disqualification - carries a suspension of five months, and any further infringement carries a suspension of nine months, starting from the date of notification of sanction. 

A rider can appeal a sanction to the Court of Arbitration for Sport, but only has a 10-day window in which to do so.

Teams also face sanctions. If two riders from the same team test positive within a 12-month period, the team is fined 10,000 CHF. In the event of any further infringement from any rider during that 12-moth period, the team may be suspended from competition for between one month and one year, although teams can escape bans based on the evidence they give to the UCI's disciplinary commission.

And what does the future hold for Nairo Quintana?

Nairo Quintana is currently eligible to race under the UCI rules. His disqualification only applied to the Tour de France, during which he tested positive for Tramadol two times.

However, Quintana had already been on the radar of the French authorities, who Central Office for the Fight against Threats to Environmental and Public Health (OCLAESP) agents searched his hotel room during the 2020 Tour de France as part of a wider investigation into pro teams.

The French police opened a preliminary investigation in 2020 into Quintana, although he insisted only legal vitamin supplements and no doping substances were found, and insisted he has "been a clean cyclist throughout my sporting life."

Quintana is on the start list for the Vuelta a España, which begins on Friday. He has released a statement protesting his innocence and stating his intention to start the race. Arkéa-Samsic have issued a statement to say they will not comment on the matter.