Mark Stuart

A version of this article published in the Pharmaceutical Journal, UK, 2002

The biggest and most successful Commonwealth Games ever, was recently staged in Manchester. Mark Stuart, superintendent pharmacist of the Athlete’s Village Pharmacy reviews the pharmacy operations that served 5000 athletes and hundreds of officials for 25 days.

The Athletes’ village pharmacy was the sole information point in the Village to assist athletes with drug information. One of the most important roles of the pharmacy was to provide advice relating to substances prohibited in sport and the restrictions regarding the use of some drugs. Many athletes concerned about their medication, particularly prior to competing, accessed this confidential service.

A specially designed computer program was used for the Games. The dispensing system was linked to the main Games accreditation database, so could access both patient’s and doctor’s details from information on their photo accreditation pass, allowing for a very secure and efficient means of patient identification. The link to the accreditation database meant minimal data entry for the dispensing pharmacist. It is the first time a system of this kind has been used at any Commonwealth or Olympic games.

During Games time, the pharmacy dispensed around 100 prescriptions daily. The busiest periods of the day were early in the morning and at night, which corresponded to when the athletes were in the village, before and after training and competition periods. A total of 1200 prescriptions were dispensed, this is slightly less than previous Commonwealth Games, and perhaps a reflection on the impeccable hygiene standards and living conditions provided for athletes in the Village. The pharmacy in the 1998 Kuala Lumpur Games dispensed 1592 prescriptions. Upper respiratory infections and acute gastro-enteritis were considerably more prevalent at these Malaysian games. The Sydney 2000 Olympic Games Pharmacy dispensed just over 4200 items, but provided a service to around 12000 athletes, compared to just under 5000 in Manchester.

The most commonly dispensed drugs were anti-inflammatory drugs. This was to be expected given the types of musculo-skeletal injuries commonly experienced by athletes. Broad-spectrum antibiotics were the next most popular class of drug prescribed, along with symptomatic cough and cold preparations. It is interesting that the use of antibiotics peaked in the days just prior to competition starting. Athletes were most concerned about optimising their health for their competition days, where a respiratory infection may impair performance. After individual competition, the athletes seemed not so worried about minor ailments. Compared to medicines used for infective illnesses, anti-inflammatory drug use was consistent for the whole period of the games.

The major type of treatment provided at the polyclinic reflected medical care necessary to enable the athletes to be able to compete, and to optimise their physical performance on their day of competition. The use of the facilities at the medical centre peaked on the day before the opening ceremony and became less as athletes finished competition.

The types and proportions of drugs dispensed were generally similar to usage seen at other international games, a reflection on the types of conditions presented within a sporting context. By comparing drug usage from the Sydney 2000 Olympic Games, seasonal and geographical variations to prescribed medication can bee seen. A much higher proportion of antifungal preparations were dispensed in Sydney, probably as a result of the warmer climate experienced during these Olympics. Antihistamines and other hayfever preparations were also more popular in Sydney owing to the Games being held in the middle of spring.

Team members from poorer, developing countries used the polyclinic facilities more frequently. The larger teams including England, Australia, New Zealand and Canada each had their own separate medical facilities within the Village, staffed by their own doctors and physiotherapists, using their own medical equipment and drug supplies.

The pharmacy worked closely with the Commonwealth Games Medical Commission and doping-control. It monitored athlete’s medication and notification of prohibited and restricted drugs according to the Olympic Movement Anti-Doping Code and individual international sporting federation laws. An example is salbutamol, a beta-2 agonist that can only be used by athletes with proven asthma or exercise-induced asthma. At urine concentrations greater than 100 ng/ml it is considered to be a stimulant, at urinary concentrations greater than 1000 ng/ml it is considered as an anabolic agent. Written notification by the athlete to confirm the medical necessity for use of this drug is necessary prior to competition. The pharmacy at the Games was responsible for collecting and collating this information. Pharmacists assisted in interpretation of medication exemption requests from athletes.

Gold medal winning athlete Kim Collins, the St Kitts and Nevis men’s 100-metre sprinter, tested positive for salbutamol in his urine. He failed to declare the medication prior to competing, which jeopardised his eligibility for the medal. The Commonwealth Games Federation Court unanimously decided that Collins should not be penalised after he underwent lung function tests following the event that proved he was genuinely asthmatic. Collins said: ‘this has taught me a powerful lesson and one that all athletes should learn from. In future I will take personal responsibility for making sure all competition requirements are met.’

Beta-blockers are banned in Commonwealth Games sports such as lawn bowls and shooting, where a steady hand is necessary. This class of drugs would give the competitor an unfair advantage. There were cases of athletes competing in these events who realised only days before competition that the medication they had been taking for long term medical conditions were prohibited according to their international sporting federation laws. There were cases where athletes sought the advice of doctors and pharmacists on alternative pharmacological treatment options, and change of therapy regimens to enable them to compete within the rules of their sport. There was one athlete who withdrew from competition from a shooting event after a beta-blocker was declared on a notification form prior to competition. A change in treatment was unsuitable for this athlete prior to competition, and competing while taking a beta-blocker would give the athlete a definite advantage over other competitors, regardless of the medical need. Athletes can face up to a two-year ban from competition if they test positive for a prohibited substance.

Diuretic use is prohibited across the board in all sports according to the Olympic Movement Anti-Doping Code. One can understand how diuretics could be unfairly used to enable judo or boxing competitors to qualify for lower weight divisions, but would not assume that diuretic use would be advantageous in a sport such as shooting. Diuretics can be used to dilute the urine and as a result may mask the presence of other prohibited substances such as beta-blockers in the urine. There was a case of a shooter deciding to change diuretic medication prior to competition after he realised that the use of diuretics were prohibited.

Awareness of prohibited substances in sport seemed to vary between sports, and also between countries. Most of the athletes in high profile events that were also Olympic sports, such as track and field, appeared to be most conscious of the international anti-doping rules. There appeared to be a need for more education to athletes from developing countries on anti-doping and also to those athletes competing in sports with less of a high global profile such as lawn bowls and shooting. These Games also have highlighted the important role pharmacists have in monitoring athletes’ medication. The doctor, pharmacist, and the athlete have a vital role in optimising medical care within ethical sporting guidelines to maintain a fair sporting environment.

UK Sport conducted the doping control tests, overseen by The World Anti-Doping Agency. Tests on over 900 athletes were processes by the Drug Control Centre at Kings College London, using gas chromatography and mass spectrometry techniques. The centre is only one of 27 International Olympic Committee (IOC) accredited laboratories in the world. All athletes that qualified for gold, silver, or a bronze medal had to provide a urine sample to doping control. A number of competitors were also randomly required to provide a urine sample for analysis during and in the week prior to competition.

A number of random blood tests were also conducted. An initial analysis performed at laboratories at local Manchester hospitals to look for abnormal blood parameters was used to indicate the use of erythropoetin, darbepoetin, and related substances. If abnormal or suspicious results were found, further investigations by IOC accredited laboratories could be obtained. Compared to previous games, fewer incidences of drug abuse was reported, this is perhaps a reflection of growing global education and awareness of fair drug-free sporting ethics by athletes.

This was the first Commonwealth Games ever, to incorporate events for disabled athletes into the competition period. The Athletes’ Village and competition venues were designed to cater for athletes of all abilities. Anti-doping rules were also consistent for athletes of any ability; the same restrictions and notification procedures apply to all athletes. Exemptions for disabled athletes on restricted substances for medical necessity are dealt with on an individual basis.

During the Games, the Athletes Village was visited by HRH The Queen and The Duke of Edinburgh who spent time chatting to volunteer pharmacists on a walkabout of the international zone in the Village, before having lunch with 60 athletes in the athletes’ dining hall. HRH The Earl of Wessex; President of the Commonwealth Games Federation, The Countess of Wessex and Prime Minister Tony Blair also inspected the facilities and met with athletes and volunteers.

Representatives from the Athens 2004 Olympic Organising Committee and the Melbourne 2006 Commonwealth Games were present for the duration of the games to oversee the running of the games. Observers took keen interest in the pharmacy, especially the relationship between the doping control division and the pharmacy services.

The pharmacy was the distribution point for information and advice on family planning and other health literature. A world games record of 150,000 condoms were distributed from the pharmacy over the Games period. This beats distribution at previous games; 70,000 at the Sydney Olympics, and 12,000 at the Salt Lake City Winter Olympics. The ‘Friendly Games’ was dubbed the ‘Over-friendly Games’ by pharmacy staff who handed the condoms out.

The pharmacy had some unique requests for medicines. Aciclovir was prescribed for a boxer with a developing coldsore, who would not be allowed to compete if it developed. Chloramphenicol eye drops were dispensed for a pistol shooter who had impaired vision from conjunctivitis and was worried his performance may be affected. Diazepam was prescribed to a hysterical coach whose athlete was sent home, after discovering that the nationality and residence of the athlete was different to the country she was competing for.

The most unusual request at the pharmacy was for a breast pump by a female athlete. The athlete had recently had a baby and wanted to expel excess milk prior to competing. The pump was delivered to Team England’s medical headquarters instead of the pharmacy at the polyclinic by mistake, and after an embarrassing hunt by concerned volunteer pharmacists, was recovered just in time to relieve the athlete before the event.

The most rewarding moment for pharmacists and other medical professionals was seeing athletes, after treatment at the Village Polyclinic, able to compete and win a medal at the Games.

The logistics of drug supply was smoothly co-ordinated by the pharmacy staff to various venues at the Games. Medical staff provided a twice-daily outreach clinic to VIP guests at a local hotel, and the residents of the Technical Officials Village. A shuttle service between these clinics and the Village Medical Centre for medicines was co-ordinated by the pharmacy, as was a courier service to the Bisley National Shooting Centre. Because the shooting centre was on the other side of the country, an initial stock of medicines was supplied for use by the doctors covering this event and was restocked by the Village Pharmacy when a prescription was sent back to the pharmacy.

Medicines were supplied to the Athletes Village Pharmacy by AAH Pharmaceuticals, Manchester distributor. The extremely tight security measures in place in the Athletes’ Village meant the delivery driver was subjected to up to 40 minutes security inspections. Personal driver accreditation requirements were necessary, as was a vehicle bomb check and a pharmacist escort into the Athletes Village. A trained squad scanned the delivery van for explosives, and the contents of each box of pharmaceuticals were examined for suspicious contents. An experience for the local driver, but a necessary across-the-board security requirement necessary for the safety of the Village. Fortunately security threats were few.  The pharmacy was situated within one of the highest security areas of the whole Commonwealth Games. Numerous police patrols and a number of CCTV units provided the utmost security for the pharmacists and the drugs kept on the premises.

At the close of the pharmacy, much of the pharmacy equipment was donated to medical representatives from Nigeria and Fiji for use at future games. These countries are each to stage similar size events with around 5000 athletes next year. The South Pacific Games will be held in Suva, Fiji in June 2003, and the All Africa Games in Lagos, Nigeria in October 2003.

The efficient running of the polyclinic pharmacy would not have been possible without the skill and expertise of the 15 enthusiastic volunteer pharmacists from across the Commonwealth including Australia, Northern Ireland and England, who dedicated their personal time and were proudly committed to the success of the games. Their contribution has made the medical facilities of the largest and most memorable multi-sport event ever to be held in this country a huge success.