Pharmacy planning for London 2012 Olympic and Paralympic Games

David Mottram, Mark Stuart, Pamela Venning

In just under three years time the London 2012 Olympic and Paralympic and Paralympic Games will begin. The massive task of planning the pharmacy services is now well underway. This article describes how the Olympic and Paralympic pharmacy planning is progressing.

New Olympic and Paralympic Pharmacy Clinical Services Group

An Olympic and Paralympic Pharmacy Clinical Services Group has been appointed by the London Organising Committee for the Olympic and Paralympic Games (LOCOG) under the leadership of Mark Stuart who was the superintendant pharmacist for the Manchester 2002 Commonwealth Games. This group formally began its planning work in April this year and comprises a team of specialist pharmacists, whose skills cover the many diverse aspects of setting up the unique world class Olympic and Paralympic pharmacy services.

The expert team comprises of:

Frances Akinwunmi

David Erskine

Margaret Hagan

Simon Keady

David Mottram

Timothy Snewin

Steve Simbler

Trudy Thomas

In total there are 7 Olympic and Paralympic medical streams under the direction of Dr Pamela Venning: sports medicine, emergency medicine, pharmacy, imaging, polyclinic, veterinary medicine, and physiotherapy.
Olympic and Paralympic medical services

There will be four Olympic and Paralympic Villages and five sites for the football venues for the London 2012 Games, each containing a fully stocked pharmacy to provide the medicines requirements of accredited athletes, Olympic and Paralympic staff, team officials, media, IOC members and members of the Olympic and Paralympic Family. In total the pharmacy services will serve the medicine needs of around 200,000 accredited people.

The London Pharmacy will be situated in a purpose built Polyclinic located in the athlete residential area. There will be approximately 17,000 people residing in the Olympic and Paralympic Village in London. The pharmacies in Weymouth and Eton Dorney will be situated in temporary facilities within the residential areas of these Olympic and Paralympic Villages.

Each of the pharmacies will dispense prescriptions written by local UK doctors and for over 1000 visiting team doctors from 205 different countries for the Olympic Games and a smaller number for the Paralympic Games. In addition to catering to the specialist medicine requirements of elite athletes, the pharmacy staff will be involved in providing information to athletes about drugs restricted in sport, with a comprehensive specialist medicines information service provided for the Games.

Role of the Olympic and Paralympic Pharmacy Clinical Services Group

The scope of the Olympic and Paralympic pharmacy services broadly fall into four categories:

1. Education and training for Olympic and Paralympic workforce and UK pharmacists
2. Olympic and Paralympic formulary development
3. Polyclinic and venue infrastructure and logistics
4. Volunteer workforce recruitment

Planning developments are outlined below.

Education and training

The scoping for an Olympic and Paralympic pharmacy education strategy has been completed and the creation of specific learning content is ready to begin. There has been excellent support from UK pharmacy organisations that will be key in delivering some of this education on a national level in the run-up to 2012. The education plan contains elements related to training volunteer pharmacy staff who will work during games time, and also to provide all pharmacists in the UK access to information they might need if they are involved in the care of athletes.

Education will therefore be targeted at three levels:

1) the volunteer workforce
2) pharmacists and pharmacy technicians working in the vicinity of Games events
3) the national pharmacy profession.

The plan is to disseminate information about the pharmacy services to the other LOCOG medical divisions and the media during the planning phase, but then to deliver specific training for pharmacy staff within and in the vicinity of Olympic and Paralympic venues immediately prior to the Games.

With the various levels of education being developed, all UK pharmacy staff whether directly involved with the Games or not, will have the opportunity to enhance their knowledge about sport and exercise medicine. In this way, it is anticipated that a legacy from the Games will be a well-informed pharmacy profession, with the prospect of the formation of a group of Pharmacists with Special Interest in Sport and Exercise, to be affiliated with the New Professional Body and Local Practice Forums.

Formulary development

A specific Olympic and Paralympic Formulary will be used for prescribing within the Olympic and Paralympic environment and all medicines supplied to accredited people for personal use will be provided at no cost. There will be unique procedures in place to assist athletes and athlete support personnel meet their rights and responsibilities under the antidoping regulations of the International Olympic Committee and the International Paralympic Committee . This Formulary will be approved by the International Olympic Committee Medical Commission.

The Olympic and Paralympic Pharmacy Clinical Services Group is currently drawing up the first draft of the formulary for consultation with the other Olympic and Paralympic medical streams and the IOC. An Olympic and Paralympic Formulary Committee will be formed during early 2010.

Pharmacy infrastructure

The polyclinic pharmacies will operate in a similar style to an outpatient dispensary. This will be the coordinating points of medicine supply for the athlete and spectator medical facilities at each of the 35 spectator venues (including the new Olympic and Paralympic Stadium and Wembley Stadium) and dozens of other training venues around the UK. The polyclinic pharmacies will be located in the Stratford, Weymouth and Eton Dorney areas as well as the five cities hosting the preliminary Olympic and Paralympic football matches (Manchester, Cardiff, Glasgow, Birmingham and Newcastle). The Olympic and Paralympic pharmacies will also coordinate and supply drugs for emergency use at all Olympic and Paralympic venues.

The plans for the purpose built polyclinic in the Stratford Village are nearing completion, which is when, with colleagues at LOCOG, the Pharmacy Clinical Services Group will begin designing the dispensary and the logistic and coordination hub for medicines at all the Olympic and Paralympic venues.

Volunteer pharmacists and pharmacy technicians

Up to 90 volunteer pharmacists and registered pharmacy technicians will be given a once-in-a-lifetime opportunity to work at the Olympic and Paralympic Games in 2012. The general volunteer recruitment will officially begin in July 2010, however, the Olympic and Paralympic medical services are now accepting expressions of interest to volunteer for a number of public test events in the run-up to 2012 and also for the Olympic and Paralympic Games.

Volunteers will be expected to offer their services for a minimum of 10 days. People who register their interest will be kept up to date with the planning of the pharmacy services and notified of opportunities as they arise. Appointed pharmacy staff will be expected to complete a number of face-to-face and distance-learning training modules before the Games in 2012.

The Road Ahead

The Olympic and Paralympic Pharmacy Clinical Service Group will continue to meet on a monthly basis and looks forward to working with a wide spectrum of colleagues in order to provide a world-class pharmacy for the 2012 London Olympic and Paralympic Games.

A version of this article was published in the Pharmaceutical Journal (UK) August 2009.

Beijing 2008 Olympic Games Pharmacy

Mark Stuart, Dezhi Wang, Rong Han, Dora Chan

Published in the Pharmaceutical Journal UK, 2008

The Polyclinic in the Beijing Olympic Village was the impressive focal point of the Olympic medical services. Along with a fully stocked pharmacy, there was a comprehensive collection of specialist departments including: radiology with 2 MRI machines, X-ray, emergency medicine, surgery and internal medicine, sports medicine and ENT. In addition, there was a physiotherapy department with over 100 treatment beds and an optometry department, which dispensed hundreds of pairs of glasses during the Games. For the first time in an Olympic polyclinic, a Chinese acupuncture clinic was available to the athletes.

The Olympic pharmacy had a prominent position near the entrance of this impressive state-of -the-art medical complex, with a design that facilitated an efficient patient journey. A team of nurses in the reception area coordinated the patient registration, notification of test results, and the generation of the prescriptions for the pharmacy.

The Olympic pharmacy

The athlete would be greeted by a pharmacist in the reception area, who would transpose the details from a handwritten prescription of a team doctor into the Polyclinic medical system. This would then generate a prescription containing a barcode. If the prescription came from a doctor within the Polyclinic, the prescription would be electronically generated.

In the dispensary, the pharmacist would scan the barcode and a dispensing label would be generated, which contained the status of the medicine according to the World Anti-Doping agency(WADA) 2008 Prohibited List. 112 prescriptions were dispensed on the Opening Ceremony day, but this number increased considerably as the Games went on.

The Beijing Olympic pharmacy was open from 8 am to 11pm. Over the Olympic period, a total of 9 pharmacists from 6 public hospitals around Beijing volunteered their services. In any one day, 5 pharmacists would cover two shifts. In addition to this team, there were 10 pharmacy students from Beijing Capital Medical University who volunteered their assistance. For the Paralympic Games, 9 pharmacists and 5 pharmacy students staffed the pharmacy.

For the equestrian events in Hong Kong, three fully-stocked pharmacies were needed and were run by 41 pharmacists. These were in the Olympic Equestrian Village, Media Village and Olympic Family Village. The Hong Kong pharmacists were all recruited from local public hospitals.

Olympic formulary

At every Olympic Games, a specific drug formulary is compiled. This covers the full spectrum of medicines needed to cover most medical scenarios. In Beijing and Hong Kong, the formulary contained 150 drugs, which could be prescribed by the doctors of the Beijing Organizing Committee (BOCOG) and the team doctors from each of the 204 countries. If team doctors required any drug that was not contained on the formulary, the pharmacy team would help to locate the drug from one of the official designated Olympic hospitals, and assist the team doctor to obtain it at their own expense.

For the first time at any Olympic Games, a supplementary set of an additional 96 medicines were available. This list was developed by the local doctors in order to offer more comprehensive treatment options if required. These non-formulary medicines were only available to visiting team doctors if there was an important clinical need.

Chinese medicines

This is the first Olympic Games where traditional medicines have been available. The Beijing and Hong Kong pharmacies stocked 4 traditional Chinese medicines: ‘Ren Dan’ and ‘Huoxiang Zhengqi’ for heatstroke, ‘Tiger Balm’ ointment for relief from insect bites, and ‘Golden Throat Lozenges’, a popular Chinese remedy for sore throats.

Although these traditional medicines were available from the Olympic Pharmacy, they were not dispensed routinely to athletes. This was primarily because they were not on the official Olympic formulary, and also because WADA recommends caution to athletes about the use of herbal preparations, whose composition cannot always be guaranteed.

Dispensing software

The pharmacists in Beijing worked with software developers to create a bespoke dispensing system for the Polyclinic. To do this, all medicines on the formulary were broken down into dose, formulation, route and quantity – this was then used to populate the database. This pharmacy software integrated with the official IOC medical record system, which is now supplied to all Olympic Games by the IOC and which contains links to the athlete accreditation database.

In Hong Kong, the existing hospital clinical management and dispensing system was adapted for use at the Equestrian Olympic Village. The clinical management system was linked up with each of the designated Olympic hospitals, which provided a one-stop platform for patient registration and laboratory and diagnostic ordering and reporting. Drugs on the Olympic formulary were flagged on the dispensing system with warnings reflecting the prohibitive drug status.

Medicines information

Martindale was used by the pharmacists in Beijing and Hong Kong as the primary reference source for global drug information. This was mainly used to access information on international drug names, and for information about foreign medicines that athletes presented with. Access to MedicinesComplete was donated by Pharmaceutical Press for use in Hong Kong. In addition, Micromedex China was used in Beijing to access patient leaflets.

Designated Olympic hospitals

There were 21 hospitals in Beijing and 2 hospitals in Hong Kong that were designated official Olympic hospitals. Each Olympic hospital appointed an Olympic affairs officer who coordinated the care of visiting patients.

If any athlete, official or Olympic Family member was admitted, their care was coordinated through a ‘green passage’ process, which meant a speedy and priority service was provided. The designated Olympic hospitals were also able to provide the Olympic pharmacies with any medicines not stocked in the Village.

Training for Olympic medical staff

The Beijing organisers provided an extensive medical education programme. This was provided not only to the medical professionals working in the Olympic Village, but also to every healthcare professional in the Beijing area. This was an impressive undertaking on a city-wide scale.

All doctors, pharmacists and nurses in each of the Beijing Olympic hospitals received specific training on the WADA list of prohibited drugs in sport, on the protocol of care for Olympic visitors, and training in English medical terminology. Some hospitals also created tools for staff to use, including lists of all prohibited drugs and the IOC notification requirements should they be prescribed to an athlete. Training leaflets were distributed to every doctor, nurse and pharmacist on prohibited drugs in sport.

The medical team also prepared cue cards to help staff communicate with non-Chinese or English speaking patients. These contained words for common medical conditions and medication counselling terminology translated into languages including Arabic, Russian, Japanese, Korean, Spanish and German.

In Hong Kong, all of the doctors, nurses, pharmacists and ambulance staff attended a number of training days in February, and were required to attend a series of operational briefings for each event. In addition, members of the UK Equestrian Association visited Hong Kong to help prepare the medical teams for the challenges of trauma management for spinal and head injuries, which are an ever-present risk at equestrian events.

This comprehensive preparation meant that all Olympic visitors to Beijing and Hong Kong received an exceptional standard of care, and athletes could be confident that the local doctors and pharmacists were well versed with the treatment of sports injuries and the restrictions of drugs in sport.

Quality testing of all drugs

The Chinese government went to admirable lengths to ensure the quality of medicines used for the Beijing Olympics. After the Organising Committee selected the wholesaler (Beijing Medicine Stock Company) by an open tender, the expected quantity of medicines to be used for the Olympic and Paralympic period was estimated. The wholesaler then sent three times this amount for quality control testing to ensure that the composition complied with strict pharmacopoeia standards. This testing was in addition to the standard Chinese quality assurance testing that the drugs had already passed.

The full quantity of medicines expected to be used was stored in a warehouse on the top floor of the Beijing Polyclinic, and the excess medicines that had passed the quality tests were stored outside the Village. During the Games, the consumption of some medicines exceeded the expected amount—this was able to be quickly replenished from the off-site stock. In Hong Kong, medicines for both the competition venues and the villages were supplied by the designated hospitals in close proximity.

This setup was quite different to the supply chain at the Sydney 2000 Olympics and the Manchester 2002 Commonwealth Games, where daily deliveries from pharmaceutical wholesalers posed logistical challenges because of the tight security, delivery and accreditation requirements to get goods inside the village.

Ancient Chinese traditions for Olympic prescribing

China has a long history of using carved stamps, or seals, as a form of a signature – traditionally known as a ‘chop’. The hundreds of visiting team doctors who were granted temporary prescribing rights by BOCOG for the duration of the Games were all issued with a personalised Chinese stamp. When writing a prescription, the pharmacy would require the doctor’s seal, as well as a written signature, to endorse the prescription. The pharmacy kept a record of each of the unique stamps issued to visiting doctors, which could be used as an added security measure to validate the prescription.

Only local BOCOG doctors had the authority to prescribe controlled drugs (only morphine and pethidine) in the Polyclinic. Specifically, only emergency doctors, sports medicine doctors, and internal medicine specialists could use them – the unique Chinese stamp ensured that the prescribing of these substances could be tracked securely.

A unique Olympic prescription form is always used at Olympic Games. These differ from regular prescriptions by the type of information that the IOC specifies must be recorded. Doctors must document the athlete’s accreditation number and country. If a restricted drug is prescribed, approval by the IOC must be obtained and shown to the pharmacy – the signatures from the athlete, doctor, and pharmacist are obtained before dispensing to indicate the informed consent of the athlete.

Satellite pharmacies at the Bird’s Nest Stadium

Each Olympic venue had a number of medical stations, including integrated facilities for the athletes and spectators inside each stadium, and medical stations outside the venues. Each public medical station contained a satellite pharmacy stocked with close to 100 drugs, mostly for emergency situations. These drugs were managed by the doctor on duty. Single doses were administered to spectators, who would be referred to a designated hospital if further treatment was required.

Emergency medicine for equestrian events

The equestrian events, particularly cross country, are undoubtedly the most dangerous of Olympic sports. In Hong Kong, 24 medical teams were positioned at any one time along the 5.7 km competition track to attend any medical emergencies during the event. Each medical team was equipped with a drug suitcase containing over 30 emergency drugs and a variety of medical equipment and consumables.

The pharmacy services of the 2008 Olympic Games were, undoubtedly, one of the best organised and executed services in Olympic history. The services have incorporated a number of new approaches to Olympic pharmacy in terms of quality assurance, medicines distribution and dispensing technology, which will provide a model of excellence for future Games.

_____________________________________________________________

Dora Chan is a pharmacist at the Chief Pharmacist’s Office coordinating the Hong Kong Olympic Pharmacy and Paralympic Pharmacy Services.

Dezhi Wang is a pharmacist at the Peking Union Medical College Hospital, Beijing, and was a pharmacist for the Beijing Olympic Village Pharmacy.

Rong Han is a pharmacist at the Beijing Tiantan Hospital, and was a pharmacist for the Beijing Olympic Village Pharmacy.

Mark Stuart is deputy editor of BMJ Best Practice. He developed the medical training programme for the Hong Kong Olympic equestrian medical team.

Pharmacy at the Melbourne 2006 Commonwealth Games

Mark Stuart BPharm MRPharmS

Bill Horsfall FPS (Aust) AACPA

Mel Blachford PhC (Aust) FPS

Published in the Pharmaceutical Journal UK, 2006

The pharmacy within the polyclinic of the Athletes’ Village at the recent Melbourne Commonwealth Games was a showcase of modern Australian pharmacy practice. Twenty volunteer pharmacists from Victoria and from other Australian states served a record 4500 athletes and 1500 team officials who converged on Melbourne for the 12 days of competition.

The pharmacy was located at the entrance to the purpose built medical centre where all medical disciplines were represented. The close proximity and frequent communication between specialist sports medicine, physiotherapy, podiatry, optometry, medical imaging and dentistry services, meant that athletes received concentrated treatment from a highly specialised multidisciplinary team, in a single visit to the polyclinic. This environment, unique to the games setting, allowed pharmacists to actively contribute clinical and pharmacological information as part of the ‘front line’ care for athletes and team officials.

The pharmacy was one of the best equipped in Games history. Since it was a purpose built building for the Games, features to optimise patient communication, including two counselling areas, were an integral part of the planning. The pharmacy had three computer terminals and a state-of-the-art barcode scanning system to reduce any possibility of a dispensing error. After an item was dispensed and labelled, the pharmacist would scan the product with a laser scanner. This would then check that the drug booked out from the dispensing system matched the product that had just been issued. Since July 2004, this electronic scanning equipment has become compulsory by law in the Australian state of Victoria.

Unlike Olympic Games, Commonwealth Games integrate events for athletes with a disability into the main competition schedule – this was first introduced for the Manchester Games in 2002. The design of the Polyclinic Pharmacy meant that athletes in wheelchairs had an easily accessible area with counselling benches at the optimum size and height, to enable them to receive equal, personalised and confidential counselling.

A modified dispensing program and hardware was developed by PCA NU Systems^®. Modifications to the ‘WiniFred^®’ dispensing system included: removing fields that would normally be used for drug costing or claim purposes, the addition of fields to record the athlete’s and prescriber’s unique Games accreditation number, and the addition of a drop down list of all Commonwealth countries to be selected for each patient. Since all the athletes resided in the Commonwealth Games Village, the name of their country was sufficient to locate the athlete if any later communication was necessary. Additionally, each prohibited or restricted medication was tagged with a clear alert message that would appear at the time of dispensing.

To compliment the verbal counselling provided by the games pharmacists, the dispensing system was linked to electronic resources including eMIMS, Therapeutic Guidelines, Facts and Comparisons, Aus DI, and APP Guide, to provide printed consumer medicines information about every drug dispensed. In addition, information about the patient’s medical condition was also given where possible – Self Care health information cards on various disease states, supplied by the Pharmaceutical Society of Australia, were given to athletes during each personal consultation with the pharmacist.

Similar to previous international games, a unique prescription format was developed. At the time of prescribing, the athletes’ and prescribers’ country and Games accreditation number would be documented on the prescription. If a restricted or permitted drug was prescribed, the prescription required further signatures of the doctor, pharmacist and athlete. This was to confirm that the athlete was aware of the status of the drug and of any therapeutic use exemption (TUE) forms that were required to be submitted to the Commonwealth Games Federation TUE Committee, before the athlete starts the treatment. Examples of drugs requiring special exemptions to be used therapeutically include: inhaled, intravenous or intra-articular corticosteroids and inhaled beta-2-agonists such as salbutamol. To ensure that the use of medication issued to athletes complied with the World Anti-doping Code, all medicines, including OTC products were supplied only on prescription. This ensured that thorough checks against the prohibited list were undertaken for every medicine issued and that a comprehensive patient history was retained.

Similar to the Sydney 2000 Olympic Games, visiting team doctors were given prescribing rights for the duration of the Games. They were able to prescribe only for athletes and officials from their own country. This practical arrangement was different to that at the 2002 Manchester Games, where only UK registered doctors could authorise prescriptions within the Polyclinic. Pharmacists from other Australian States were given free temporary registration by the Pharmacy Board of Victoria to enable them to practice at the Polyclinic for the duration of the Games. This registration process was made possible by the Victorian Government’s Special Events legislation.

A specific formulary was developed in collaboration with MIMS Australia for use within the Polyclinic. It contained a comprehensive range of medicines, including many to specifically treat sports injuries such as: topical and oral NSAIDs, injectable corticosteroids, and topical preparations for sprains, strains and bruising. It also contained information about the status of each drug in sport, and information for local and international doctors about the unique prescribing process within the Polyclinic.

The Melbourne 2006 formulary contained more comprehensive prescribing advice than those of previous Olympic and Commonwealth games. Unlike previous formularies, it also provided detailed information about contraindications, precautions, adverse reactions and interactions. In addition, all visiting team doctors and the polyclinic pharmacy received a copy of MIMS Bi-monthly, donated by MIMS Australia.

Providing medicines information to athletes and to both local and visiting international healthcare professionals was a key role for this Commonwealth Games Pharmacy. A comprehensive range of information sources enabled pharmacists to search local and international references quickly. Pharmaceutical Press donated access to the online MedicinesComplete for the duration of the Games, which enabled access to references including: Martindale, BNF, Stockley’s Drug Interactions, Dietary Supplements and Herbal Medicines. MedicinesComplete was frequently used to identify foreign drug preparations that athletes were already taking and to find local Australian equivalents. Other reference books available to pharmacists included the Australian Therapeutic Guidelines, Australian Medicines Handbook, Merck Manual and the Australian Pharmaceutical Formulary, donated by the Victorian Pharmacy Guild.

All drugs in the Polyclinic Pharmacy were supplied free of charge to all athletes and officials. The pharmacy was supplied by Australian Pharmaceutical Industry (API) wholesalers who delivered one order daily. The pharmacy team also facilitated the supply of bulk medicines for use by some of the larger teams including England, Canada and Scotland who had their own independent medical facilities onsite in the Village. A direct ordering route was established between them and API, and these orders were delivered via the polyclinic pharmacy. This is the first time such an arrangement for visiting teams has been in place for a Commonwealth Games. The pharmacy also facilitated the supply of medicines to other sports venues for sports including: swimming, athletics and cycling.

Links with the pharmacy department at the Royal Melbourne Hospital and a local community pharmacy were established prior to the Games. During Games time, additional urgent medicines could be obtained from these places at short notice and after hours.

With some of the pharmacists having also worked at the Sydney and Manchester Games, this event provided an opportunity to follow up on the medical services of these previous Games. After Manchester, the reference books were donated for use at the 2003 All Africa Games in Nigeria, and some pharmacy equipment was donated for use at the 2003 South Pacific Games in Fiji. Team officials from both countries reported to the Melbourne Polyclinic that these were a welcomed and much utilised resource at these huge events.

The unique games environment provided pharmacists with a constant supply of challenges not usually encountered in normal practice. Knowledge of the anti-doping code, musculoskeletal medicine and tropical and contagious diseases was often put to the test.

The Polyclinic had two admissions for patients with malaria who required drug treatment, one of which required their existing malaria medication to be identified and re-supplied. There was also a case of chickenpox in one of the hockey players from a visiting team – the pharmacy obtained urgent supplies of varicella vaccine for use by some of the other players in the team. Maintaining the cold delivery chain for this live vaccine during a 40 degree heatwave in Melbourne was another logistical challenge for the pharmacists.

The evocative and quirky opening ceremony to the Games culminated in a spectacular fireworks display inside the Melbourne stadium, watched by the athletes from within the centre arena after marching in. Considerable smoke and flying ash from the display resulted in a number of admissions to the polyclinic straight after the ceremony and the next morning. Dubbed ‘fireworks eye’ by the polyclinic pharmacists, some 15 prescriptions for lubricant or anti-inflammatory eye drops were dispensed for athletes with irritated eyes immediately after the ceremony. The volume of prescriptions for eye injuries also peaked following the boxing events where a number of athletes were treated for injuries.

Similar to the Sydney Olympics, allergies and insect bites were one of the most common conditions that patients presented with. A number of athletes were bitten by insects including mosquitoes, with one experiencing severe symptoms requiring administration of an intravenous corticosteroid that required a TUE. A few days of extreme heat early in the Games seemed to exacerbate the incidence of sunburn, itchy skin rashes and dehydration.

An average of around150 prescriptions were dispensed daily. The numbers of prescriptions peaked at 194 the day before the opening ceremony and slowly reduced as the Games progressed. Compared to the Manchester Commonwealth Games, of a similar number of competitors, the average number of prescriptions was around 50 percent higher. By observation, this seemed to be due to environmental influences such as a warmer climate, and the presence of insects and local flora causing a greater incidence of allergic reactions.

Prescriptions for sports related injuries accounted for the greatest proportion of dispensed medicines. Topical diclofenac gel was the most dispensed item, with nearly 200 tubes dispensed over the Games period. Oral diclofenac and paracetamol were also among the fastest movers. Anti-allergy preparations including loratadine and oxymetazoline nasal sprays were the second- and third-most popular drugs dispensed, closely followed by preparations for cough and colds. Interestingly, a number of pregnancy tests were also dispensed.

To assist doctors in prescribing treatments for cough and colds, standard drug protocols were developed for different sets of cough and cold symptoms. Doctors were able to quickly select a protocol that best matched the patient’s condition. Criteria for selection of these protocols depended on variables including: no CNS stimulation, dry or productive cough, and the presence of pseudoephedrine or phenylephrine. Doctors would simply prescribe ‘standard cold treatment X’ – pharmacists would then dispense the product combination and provide the necessary counselling to the patient.

One of the highlights for the Commonwealth Games pharmacists was royal visits to the polyclinic by Her Majesty, Queen Elizabeth, HRH Prince Philip and HRH Prince Edward. They observed the routine running of the polyclinic and greeted the pharmacists on duty before having lunch with athletes in the huge Village dining hall. Oddly, the protocol department for the Games insisted that the free condoms available in the waiting area be removed from sight for the duration of the visits, despite the Queen’s recent Australian speech expressing her concerns about HIV/AIDS in developing countries. The Prime Minister of Australia, John Howard, Victorian Premier Steve Bracks, and His Excellency the Governor General of Australia, Michael Jeffrey, also visited the polyclinic and observed the running of the pharmacy.

The Melbourne 2006 Commonwealth Games Pharmacy has set a new standard of excellence for pharmacy at future Games.

Turin 2006 Winter Olympic Pharmacy

Mark Stuart

Published in the Pharmaceutical Journal UK, 2006

 

Given the spread of Olympic venues across the mountains surrounding Turin, three separate Olympic Athlete Villages were purpose built. One Village was in central Turin and two near the mountain venues: Sestriere and Bardoneccia. Each Village had a separate Polyclinic which provided athletes with the full range of medical services including a new purpose built pharmacy on each site.

Each of the three pharmacies was open from 8am until 10pm daily with emergency overnight services. The facilities were staffed by two pharmacists at any one time, who were assigned one week periods to manage the operation of each pharmacy. Pharmacies were restocked on a daily basis, with the distribution point of all drugs being the regional Italian government pharmaceutical authority that serves the Turin region.

A specialised drug formulary was developed by the Turin Organising Committee (TOROC) Healthcare Program and included the list of drugs available free of charge to athletes and Olympic and Paralympic Family members. A copy of this formulary was distributed to each team prior to the start of the Games.

The formulary contained a selection of drugs from the most common therapeutic categories. For example, antibiotics available for prescribing were: amoxycillin, Augmentin, cefaclor, ceftazidime, ceftriaxone, ciprofloxacin, doxycycline, erythromycin, imipenem, levofloxacin, metronidazole, and Bactrim. NSAIDs, which are the most commonly prescribed drug in sports medicine, included: celecoxib, diclofenac, ibuprofen, ketoprofen, and aspirin. The relatively moderate altitude of the mountain venues meant that drugs to specifically treat altitude related conditions were not specifically considered as a therapeutic group in the Olympic formulary. Interestingly, the Winter Olympic Drug Formulary reflects similar doses and indications that are in the official national Italian formulary, which is based directly on a translation of the British National Formulary.

The dispensing program had a built-in function to alert the dispensing pharmacist when a prohibited or restricted substance was being dispensed. If a prohibited substance had to be dispensed, the doctor was required to explain the consequences to the athlete, and both the athlete and doctor would sign the prescription. The pharmacist would then confirm with the prescriber that a prohibited substance was dispensed and the prescribing doctor or the Polyclinic Director would notify the IOC that a prohibited substance had been issued.

For the duration of the Olympics and Paralympics, the Italian Ministry of Health allowed visiting medical doctors to provide their usual range of services to members of their own team. This enabled them to use pharmaceuticals from the team supply and prescribe formulary medicines on official Olympic prescriptions to be dispensed from the Polyclinic Pharmacy. They were also given the right to order diagnostic examinations, medical imaging and laboratory tests from the Polyclinic for their own team.

The shipment of medicines into Italy by individual teams for their own use was coordinated by the Ministry of Health, Customs Authorities and TOROC. A full inventory of medications that wished to be imported had to be submitted by each team to these organisations prior to the Games.

The pharmacy services covered the period of the Olympic Games and will stay open until the close of the Villages after the Paralympic Games in late March.

Doping Control for the 2006 Turin Olympic Winter Games

Mark Stuart

Published in the Pharmaceutical Journal UK, 2006

Implementation of the doping control program began as a challenge for the Organisers of the XX Olympic Winter Games in Turin. Normally, the International Olympic Committee (IOC) disqualifies and expels athletes for doping at the Olympics, but does not issue or support criminal penalties. However, under Italy’s strict anti-doping law, athletes can face criminal sanctions for drug offences.

Drug testing at national and international sporting events in Italy is usually conducted by the Italian Health Ministry. In the months before the Games, the ministry undersecretary threatened to send police to conduct drug tests on Olympic athletes during the Games, to ensure that Italian law was being complied with and that criminal sanctions were issued when a doping offence was found. After ongoing discussions with the IOC, the Italian Health Ministry eventually backed down from its demand to conduct tests during the Games and put the IOC in charge of all testing. However, no change was made to the law imposing criminal sanctions, which the Ministry stated is aimed at protecting the health of athletes.

International doping collaboration

This is the first Winter Olympic Games since the World Anti-Doping Code has been accepted by all major sport federations and over 180 governments, making it the most robust anti-doping program at any Winter Games to date. The International Olympic Committee stipulates that any sport wishing to be a part of the Winter Olympic Program must have accepted and implemented the World Anti-Doping Code, which outlines the process by which drug testing should be conducted and also provides the list of substances prohibited or restricted in sport. To enable governments to fully implement this code which was accepted in 2003 in time for the Athens Games, a two part process was undertaken.

Firstly, governments had to sign the Copenhagen Declaration which was the political document indicating governments’ commitment to the code. The second step was for governments to implement the International Convention against Doping in Sport, which was backed by UNESCO. This convention provided individual countries with the practical means of harmonising their local policies with the code. At present, individual governments are in the process of amending local doping control practices to comply with this global policy.

With its zero tolerance approach to doping, the IOC, together with the World Anti Doping Agency (WADA) and the Turin Organising Committee (TOROC) was responsible for the anti-doping operations at these Winter Games. Under the authority of the IOC, TOROC was responsible for implementing testing at all the Olympic venues, and WADA implemented the testing for athletes who resided or trained outside the Olympic venues. The management of the laboratory results and any sanctions imposed on athletes who test positive for a prohibited substance was the sole responsibility of the IOC.

Olympic drug testing

Around 1200 tests were conducted over the entire period of the Winter Olympic Games. This covered the four weeks from the opening of the Athlete Village until the Closing Ceremony on February 26. Given that there were around 2500 athletes competing, the likelihood of being tested was very high and inevitable for all medal winners.

The number of urine tests was 20 percent more than the previous Winter Games in Salt Lake City and for the first time in Winter Olympic history, blood tests were conducted. This resulted in around a 70 percent total increase in the number of tests performed than the Salt Lake City Games. An additional 280 samples will be collected and tested throughout the duration of the Paralympic Games.

Olympic laboratory

In January 2004, WADA was responsible for accrediting 33 laboratories worldwide. This ensured that they all met the international standards of quality for the testing for prohibited substances in urine and blood samples. In Italy, the laboratory accredited was the Laboratorio Antidoping in Rome. This laboratory was given the responsibility of processing all of the Olympic doping tests, with its activities closely overseen by WADA.

In order to process the huge volume of tests quickly, this whole laboratory was relocated to Turin for the duration of the Olympic and Paralympic Games. A brand new temporary laboratory was built within the premises of the hospital in Orbassano, Turin for this purpose, which will be handed back to a local anti-doping consortium after the Games. The laboratory was staffed by 45 scientists, but the total team including support staff totalled around 80 people.

Prohibited substances

The full range of drugs on the prohibited list was tested for during the Olympic and Paralympic Winter Games competition period. The categories of prohibited substances include: anabolic agents, stimulants, hormones (and related substances), beta-2 agonists, anti-estrogenic agents, narcotics, cannabinoids, corticosteroids, diuretics and other masking agents.  The full current list of prohibited substances can be found on the WADA website (www.wada-ama.org).

In addition, athletes competing in some Winter Olympic sports are subject to testing for specific substances that are considered performance enhancing for that particular discipline. For example, beta blockers are prohibited and tested for in curling, bobsleigh, ski jumping, freestyle aerial skiing and snowboard half pipe events, where they may be used to reduce tremor and to increase the athlete’s ability to maintain precision during manoeuvres. They may also be tested for in athletes competing in the biathlon which is a combination of cross country skiing and target shooting—beta blockers can steady the hand which may be advantageous in the shooting component of this event.

Doping control facilities at Olympic venues

Each of the 14 Olympic competition venues had a new purpose built doping station, comprising of an athlete reception and waiting area, clinical room and toilets for the collection of urine samples. In addition, there was a larger doping station within each of the three Athlete Villages with facilities for collection of blood samples.

The doping station at each venue was responsible for a combination of random sample collection at preliminary and qualifying events, as well as collection of urine samples from each of the medal winners. Each medal winner was also required to report for a blood sample collection within 24 hours of being notified, at one of the larger doping stations at an Athlete Village.

The doping control team comprised of volunteer doping experts from all over the world. A large proportion of the doping escorts were from Turin who, in addition to Italian, spoke either one of the official Olympic languages: English or French. They were responsible for notifying the athletes either immediately after they compete, or within the Village, that they have been selected for a test. Local doctors would then act as the doping control officer who would oversee the actual urine or blood collection and paperwork back at the doping station.

Within each of the larger stations at one of the three Athlete Villages, up to 14 doping control staff were on duty at any one time. This enabled a quick response to faxed notifications from the IOC Medical Commission for random sample collection within the Village.

The World Anti-Doping Agency

The World Anti Doping Agency had a very prominent presence in Turin and was responsible for a number of important activities to support both the anti-doping operations of the Games and to provide education to athletes. This included responsibility for pre-Games testing, the monitoring and review of any therapeutic use exemption given to athletes taking medicine for therapeutic use, and the monitoring of any sanctions given to athletes by the IOC during the Games.

Independent WADA observers from around the world were assigned to oversee and report on the activities of individual doping stations at different times. This was to ensure that all phases of doping control were being carried out appropriately and in a fair unbiased manner.

Additionally, the WADA Athlete Outreach Program had a stand at each of the three Athlete Villages and provided athletes with information about doping issues. The stands were staffed by anti-doping experts and retired athletes from around the world. Athletes were encouraged to take part in a doping quiz to win prizes to help enforce the quality and credibility of the anti-doping message. Educational material including an athlete guide to drug testing and copies of the prohibited list were available in many languages. The WADA Outreach Program will also be present at the forthcoming Commonwealth Games in Melbourne, Australia.

Manchester 2002 Review of Pharmacy Operations

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.

Manchester 2002 Commonwealth Games Pharmacy Preparations

Mark Stuart

Published in the Pharmaceutical Journal, UK, 2002

With only days until the XVII Commonwealth Games, the largest sporting event ever to be held in the UK, and highlight of the Queen’s Jubilee celebrations, excitement is mounting as organisers are nearing the conclusion of many years of preparation. Around 5000 athletes from 72 countries will converge on Manchester to compete from the 25th of July to the 4th of August. Mark Stuart, superintendent pharmacist of the Athletes’ Village Medical Centre Pharmacy, gives an insight into the pharmacy preparations.

Over the last year and a half, a dedicated pharmacy-working group consisting of pharmacist representatives from NHS trusts in the Greater Manchester area, as well as a number of pharmacists involved in sports medicine, has been meeting monthly.
The pharmacy-working group has constructed policies, procedures, and developed the services that the pharmacy will provide. They have anticipated the many unique issues that an event of this type will present.

The pharmacy will be part of a purpose built polyclinic in the heart of the Commonwealth Games Village. The University of Manchester Fallowfield campus student accommodation will be transformed into the Village, a buzzing metropolis of international athletes during the time of the Games.

This is no ordinary pharmacy. The patients in the Village will include elite athletes of many nationalities and cultures. It will act as the distribution point for drugs needed by doctors at 15 venues around Manchester including the new 38,000 seat capacity City of Manchester Stadium and will vigilantly monitor athlete’s medication according to international anti-doping laws. A custom designed dispensing program will alert the pharmacist at the time of dispensing, to the status of a drug in relation to sporting law. All medication, including OTC drugs, will be dispensed only on prescription, further reducing the risk of athletes taking a prohibited substance.

The pharmacy team will ensure that athlete drug treatment complies with the Olympic Movement Anti-Doping Code. This is the internationally recognised list of substances that are prohibited or have restrictions when used by competing athletes. The list of prohibited substances includes the classes- stimulants, narcotics, anabolic agents, diuretics and peptide hormones. Substances prohibited in certain circumstances include alcohol, cannabinoids, local anaesthetics, glucocorticosteroids, and beta-blockers.

Pharmacists will also be monitoring the way drugs are administered to comply with this code. For example glucocorticosteroids are permitted only when used locally or intra-articularly when medically necessary. Use of formulations which result in systemic absorption, such as oral, rectal, or intravenous or intramuscular injections are prohibited. Likewise, only local or intra-articular injections of local anaesthetics can be administered when medically justified.

The pharmacy-working group has produced a formulary specifically for the Games, which reflects the requirements of sports medicine and necessary medical care for athletes, officials and staff. A wide range of anti-inflammatory drugs have been included and are expected to be frequently prescribed, as has proven to be the case at previous games. There will be a dense population of people living in the village, thus having a broad spectrum of anti-infective medicines on the formulary has been important, given the potential infection control issues that this situation may present.

The formulary lists the status of each drug according to the Olympic Movement Anti-Doping Code and requirements for notification prior to competition should it be necessary. For example an athlete can use salbutamol, which falls into the stimulant category, only if they have proven asthma or exercise induced asthma. Written notification by the team doctor is necessary before the athlete competes. Similarly for insulin, which is permitted only to treat athletes with insulin-dependent diabetes. The formulary contains information on prohibited substances necessary to promote a fair sporting environment.

The whole spectrum of medical services will unite to provide the highest standard of healthcare to the ‘Games Family members’ which are athletes, team officials, and support crew. Those volunteering their services include sports doctors, dentists, podiatrists, pharmacists, physiotherapists, optometrists, and nurses.

A team of 16 enthusiastic volunteer pharmacists from all over the UK has been selected to run the pharmacy from the time the Village opens on the 15th of July, till the close of the Village on the 7th of August. An interest in sports medicine, and availability for the Games period was part of the selection criteria. They will be provided with an official Games uniform including a flat cap, to be worn backwards in keeping with the spirit of the Manchester area. They will also receive free meals and transport while they are working.

Volunteer pharmacists have had the opportunity to attend a number of training days, to prepare them for this special event. Training has covered issues specific to working in a games environment. Topics included- prohibited substances in sport, doping control, dealing with the media, confidentiality, security in the Athletes’ Village, radio communication, and professional interaction with the athletes. Volunteers recently attended a pharmacy specific training day after the Village was completed, where they could familiarise themselves with the new Village Medical Centre and inspect the facilities prior to opening day.

A drugs-in-sport information pack has been sent to pharmacies in close proximity to the Village, NHS emergency departments, and pharmacies at Manchester Airport, who are most likely to come into contact with athletes requiring medication around the time of the Games. The pack contains information on what athletes can and can’t take according to the Olympic Movement Anti-Doping Code. It is hoped the packs will prevent athletes from inadvertently taking prohibited substances, particularly those found in OTC preparations.

A number of drug companies have shown their support for the Games. Bayer, Castlemead, Crookes Healthcare, Schering Plough and Shire Pharmaceuticals, have generously donated some supplies for dispensing from the Village Medical Centre Pharmacy. The National Pharmaceutical Association is subsidising indemnity cover for the volunteer pharmacists and The Royal Pharmaceutical Society has lent essential reference books for the Games period.

This is an exciting opportunity for pharmacists to be involved in an international sporting event and be part of a medical team, caring for elite athletes from around the world. The pharmacy team will deliver a unique service to athletes and will help to maintain a fair sporting environment. This year’s XVII Commonwealth Games is set to be the biggest and best yet.

Athens 2004 Olympic Pharmacy

Mark Stuart, BPharm PGDipCDDS DipBotMed MRPharmS
Maria Skouroliakou, Director of Pharmacy, Athens 2004 Olympic Games

Published in the Pharmaceutical Journal UK, 2004

The Polyclinic Pharmacy in the Athens Olympic Village opened on July 30 to provide the pharmacy requirements of over 17 000 athletes, team officials and technical officials from 202 countries. The Pharmacy provided medicines to residents of the Olympic Village and acted as a central point of organisation, coordination and distribution of drugs to the satellite pharmacies at each of the Olympic sporting venues. Pharmacists worked alongside other medical experts in a closely-knit environment to provide a world class level of medical care to the ‘Olympic Family’.

In addition to the pharmacy, the Polyclinic also contained a comprehensive range of medical services and specialties which included: sports medicine, medical imaging, podiatry, physiotherapy, dentistry, physiotherapy, pathology, eye services including opticians and ophthalmologists, orthopaedics, and gynaecology. With its contemporary design, brand new high-tech medical equipment and marble floors throughout, the Polyclinic functioned as a complete luxury hospital and state-of-the-art sports medicine clinic.

An extraordinary total of 3000 medical staff was required to run the medical programme for the Games. This included 400 specialist doctors, 400 nurses, 400 physical therapists, 200 masseurs, 40 dentists, 30 opticians and 20 podiatrists. 170 ambulances and 3 helicopters were also on-the-ready to cope with any medical emergencies that arose. The medical services within the Olympic Village worked closely with the Greek Ministry of Health and Welfare to ensure that patients requiring additional medical treatment other than that provided in the Polyclinic could be transferred to a network of dedicated Olympic hospitals. The Polyclinic pharmacy was staffed by 12 pharmacists and 10 pharmacy students from Athens University. There were 2 shifts during the day from 8am to 3pm and 3pm to 10pm; an on-call pharmacy service was provided overnight.

A pharmacy guide outlining the Games formulary and prescribing procedures was supplied to each participating nation. The formulary included information about the status of each drug in sport and information about notification procedures for restricted drugs requiring a therapeutic use exemption, such as beta-2-agonists and corticosteroids. Since many of the large teams bought their own supply of medicines, the formulary also contained information about the importation of drugs into Greece. Eight months before the Games, each National Olympic Committee was requested to declare all medications they planned to bring into the country to ensure that there could be no inadvertent breach of customs and importation laws. Special allowances were made for visiting team doctors to prescribe only for members of their own country’s team for the Olympic period.

All medicines and medical services were provided completely free of charge to the athletes and officials. 270 different medicines were listed on the formulary and available for prescribing. Although a considerable amount of drug stock was donated by pharmaceutical companies, the total cost of drugs for the pharmacy came to 240,000 Euro.

The computer dispensing system was custom designed for the Athens Games and seemed to combine the most successful elements of the dispensing programmes from the Sydney Olympics and Manchester Commonwealth Games. The system was linked to the athlete accreditation system and was able to display all the details of the athlete by simply entering the athlete’s identification number. The system was also linked to the other medical systems within the Polyclinic to provide the pharmacist with detailed information about the prescribing doctor and the Polyclinic admission details. The system would alert the dispensing pharmacist if any prohibited or restricted drug was dispensed and would print a duplicate prescription for the athlete to keep.

A total of around 100 to 150 prescriptions were dispensed daily. Similar to previous games, anti-inflammatory drugs including diclofenac were most frequently prescribed for soft-tissue injury. Antibiotics and loratadine were also in high demand, as were simple eye drops for dry, irritated eyes; the consequence of 36 degree temperatures on some days and a dry and dusty atmosphere. Simple analgesic medications were dispensed by prescription only and fast-movers included paracetamol and orphenadrine. The Polyclinic Pharmacy was also responsible for distributing 130 000 free Durex condoms and 30 000 sachets of personal lubricant. Pharmacy involvement in safe-sex campaigns is becoming a tradition at international games.

The Olympic Pharmacy was given access to the recently launched Medicines Complete by Pharmaceutical Press for the period of the Olympic and Paralympic Games. This comprehensive electronic information package could be used for the identification of drugs and product names from foreign countries and allow pharmacy staff access to information on a range of nutritional supplements frequently used by athletes.

To cope with the increased pharmacy demands of millions of visitors to Athens, the Olympic Organising Committee and pharmacists representing the pharmaceutical industry and local businesses came to an agreement for the operation and restocking of essential medicines around Athens during the Olympic period. The number of pharmacies open on the weekends and overnight were increased especially around Olympic venues, downtown Athens and the port of Piraeus. Provisions for the restocking of pharmacies during evening hours were implemented.

The polyclinic pharmacy will remain open until October 1st to serve the athletes and officials of the Paralympic Games.

Athens 2004 Doping Control

Mark Stuart

Published in the Pharmaceutical Journal UK 2004.

The ruthless desire to compete and win is as old as humankind. Ancient Greek Olympians are known to have used stimulating potions and high protein diets to improve athletic performance and Greek gladiators were doped to make their fights more vigorous and bloody for the spectators. It seems doping in sport has gone full-circle, with Greece having just undertaken the largest and one of the most successful Olympic doping-control operations ever.

In the year preceding the Athens Games, the war on drugs in sport was well underway. The sporting world was rocked by a number of positive drug tests and allegations of drug use by elite athletes. Britain’s favourite for a gold medal in Athens, sprinter Dwain Chambers was suspended for 2 years following detection of the ‘designer’ steroid THG. Another British Olympic hopeful, cyclist David Millar withdrew from the British team only weeks before the Games after admitting to a French judge he had used EPO. Vials of the drug were found by police in a raid of his home just prior to the Tour de France. He was to compete in at least three Olympic events: the time trial, road race and team pursuit.

Also in the weeks before Athens, Australian cyclist Sean Eadie was cleared of allegations that he had imported prohibited substances into Australia, while in the USA, owner of the Bay Area Laboratory Co-Operative, Victor Conte, faced charges of supplying performance enhancing drugs to a number of American athletes. Although she has never failed a drugs test, triple Olympic gold medallist Marion Jones was also fighting to clear her name from suspicion of cheating after her ex-husband claimed she injected performance enhancing drugs while competing at the Sydney Olympics.

With each Olympics, drug taking and drug testing gets more sophisticated. Anti-doping authorities are constantly developing more advanced ways to keep ahead of the cheats. At the Sydney 2000 Games EPO testing was conducted for the first time. Both a blood and urine test was used at these games to identify EPO use. The detection of EPO can now successfully be done by a urine test alone and the Athens Games were the first Olympics to use such technology.

Also for the first time, human growth hormone testing was introduced for Athens using a test developed by scientists at Southampton University. Although this substance has been on the banned list since 1989, until now the detection of this substance was not possible. An initial test can detect if human growth hormone has been used by the athlete in the last 36 hours and a second test can detect if it has been used in the previous 84 days. During the Games period, Olympic athletes were randomly selected to provide a blood sample to test for possible abuse of human growth hormone.

The doping control operation in Athens was one of the biggest in Olympic history, with the number of staff exceeding 500. The IOC was responsible for a total of around 3500 urine and blood tests over the period of the Olympic Games and the test events. WADA sent independent observer teams to the Athens Games, to ensure that the doping operations were conducted in a fair and unbiased manner.

The ‘in-competition’ period of the Olympics was considered to be from the opening of the Olympic Village on July 30 to the day of the closing ceremony on August 29. During this time, tests were conducted for all prohibited substances which include stimulants, narcotics, cannabinoids, anabolic agents, peptide hormones, beta-2 agonists, anti-oestrogens, masking agents and corticosteroids. A further 650 tests are expected to be conducted for the Paralympic Games in the weeks to follow.

Both the IOC and WADA conducted random tests from the doping control station within the Polyclinic at the Olympic Village in the 2 weeks before the start of the Games. After this time the IOC was responsible for the collection and testing of samples. After the start of the Games, each of the gold, silver and bronze medal winners were required to provide a urine sample at the doping control station at each venue for testing. Another athlete within each event was also randomly selected to provide a sample and athletes were randomly selected during the qualifying heats.

Each morning, in the 2 weeks before the start of the Games, the names of athletes selected for testing would be randomly drawn and one athlete’s name would be assigned to a doping-control escort. The escort would then have the often difficult job of locating the athlete in the Village and notifying the individual to report for a blood and urine test. The escort would then observe the athlete closely until they reported for testing to ensure that they did not partake in any activity that may hinder the detection of banned substances.

The Doping Control Laboratory was located at the Athens Olympic Centre and was accredited by the World Anti-Doping Agency (WADA) to conduct the laboratory tests for the Games. This was the first time in Games history that accreditation of testing facilities was assumed by WADA. In previous years the International Olympic Committee (IOC) has been responsible for laboratory accreditation. The laboratory was capable of processing 180 samples daily with the negative results available within 24 hours and the positive results in 36 hours.

If an adverse lab result was found, the IOC Medical Commission was immediately notified. It would then inform the IOC president who would set up a Disciplinary Commission. The athlete would be informed and could request the analysis of the second sample with the right to be present for the opening and analysis of the second sealed container. The athletes had the opportunity to defend themselves at the disciplinary hearing after which the IOC executive board would make the final decision. An appeal for this decision could further be made to the Court of Arbitration for Sport.

The World Anti-Doping Code was introduced by WADA for the first time at these Games. It was mandatory for participating countries to accept and implement the Code by the day of the opening ceremony. The Code aims to harmonise anti-doping regulations across all sports and all countries. The new code provides a uniform basis for anti-doping policies, rules and regulations for sporting organisations around the world. It also provides requirements for sanctions and hearings should an athlete test positive. It also outlines testing procedures and allowances for therapeutic drug use exemptions.

Prior to the opening of the Olympic Village on July 30, WADA carried out worldwide testing on athletes who qualified for the Games, with particular attention paid to athletes in countries that do not have a national anti-doping agency in their home country. Within the Village WADA also conducted an athlete outreach program, where representatives were present to provide information and education about anti-doping and to encourage fair, drug-free sport.

A doping control guide, produced by the Athens 2004 Organising Committee was distributed to all national Olympic committees and international sporting federations prior to the games. The guide outlined the doping-control rules, doping-control program, and detailed sample collection procedures for the Games. It also included the most recent list of prohibited substances and methods which was updated in March this year.

British athletes competing in Athens were given a medical kit to treat minor ailments while away from home. The aim of the kits was to prevent the occurrence of positive drug tests from over-the-counter medicines, as happened to Alain Baxter at the 2002 Winter Olympics after using an OTC inhaler. The kit contained anti-doping information from UK Sport and a selection of permitted medicines which included paracetamol, throat lozenges, a nasal spray and anti-diarrhoeal medication.

 

Sydney 2000 Olympic Pharmacy

Mark Stuart

Published in the Pharmaceutical Journal UK, 2001.

I was fortunate to have the opportunity of working as a pharmacist at the pharmacy in the athletes’ village at the Olympic Games in Sydney, Australia, last year. It gave me a unique insight into sports medicine and the operation of an Olympic pharmacy. A team of 20 volunteer pharmacists was chosen from nearly 1,000 applicants from all over Australia to operate the pharmacy over the two-week period of the games, providing a service to nearly 12,000 athletes.

The pharmacy was within the polyclinic in the village, along with other medical services including sports medicine, physiotherapy, radiology, dentistry, massage, hydrotherapy, opthalmology, an emergency department with three intensive care beds, and general medical consulting services. A team of doctors, nurses, pharmacists and other health care professionals made up the medical team, all volunteering their services for the duration of the games.

The polyclinic services were available to all residents of the village, mainly athletes and team officials. The pharmacy was open from 8am to 11pm daily and a 24-hour on-call service was available from a resident pharmacist. At any one time there were up to five pharmacists on duty, processing around 250 prescriptions daily, approximately 70 per cent of these to athletes.

The most commonly dispensed drug was diclofenac in tablet form, mainly to athletes with muscle injuries. Other anti- inflammatory drugs were frequently dispensed including celecoxib, diclofenac topical gel and piroxicam gel. Another popular drug was loratadine, a non-sedating antihistamine. Sydney’s spring weather seemed to bring out allergies in foreign visitors.

Antifungal preparations were in huge demand. Athlete’s foot was a common complaint. Hundreds of tubes of antifungal creams were dispensed, the most common containing miconazole and clotrimazole.
Antibiotics
It was unfortunate that some athletes caught colds and respiratory infections as this may have impaired their performance. Antibiotics including amoxicillin, co-amoxiclav, and ciprofloxacin were fast movers along with decongestant nasal sprays, cough syrups and sore throat lozenges.

Given the location of Australia and the large time differences to many countries, it was not surprising that jet lag was experienced by many athletes and officials arriving close to the start of the games. It was important for the athletes to normalise sleeping patterns quickly to maintain peak performance. Some sedative drugs were dispensed for this purpose.

Thousands of dollars worth of drugs were dispensed free of charge to residents of the Olympic village. A large Australian pharmaceutical wholesaler was the main supplier of drugs to the pharmacy. In its warehouse a separate section was allocated for the packing and dispatch of drugs for the Olympic pharmacy. Daily deliveries were received after the order had first been approved by the Olympic Organising Committee head office. A number of drug companies donated stock for use during the Olympics.
IOC guidelines
A computer dispensing program was specifically designed to meet the needs of the pharmacy. When a drug was dispensed the program would alert the pharmacist as to the status of the drug in accordance with International Olympic Committee guidelines on restricted substances in sport.

Drugs could fall into any of three categories. Permitted substances were not subject to usage restrictions in sport. Prohibited substances were not to be used by any competing Olympic athlete. Prohibited substances included drugs such as anabolic agents, stimulants, narcotics, diuretics, peptide hormones, hormone mimetics and hormone analogues. Other drugs, such as beta-blockers, are prohibited only in certain sports, including aquatics, archery, football, shooting and sailing.

Certain drugs, including inhaled b2- agonists, eg, salbutamol and terbutaline, are classified as “Restricted with notification” substances and are permitted for use by competing athletes only with prior notification to the International Olympic Committee.

Extreme caution was exercised when dispensing any drug to competing athletes to ensure that doping control guidelines were met. Administration routes for drugs needed close observation. Eye-drops containing prohibited beta-blockers, eg, timolol, can be absorbed systemically. Betamethasone, a corticosteroid, was prohibited when administered orally, rectally and by intramuscular and intravenous injection, but intra-articular and local injection were permitted.

Pharmacists were also asked to check that certain dietary supplements, eg, protein powders, did not contain restricted substances. Although used by some athletes, herbal medicines could not be guaranteed as permitted, as constituents can be unpredictable and possibly result in a positive drug test. For example the herb Ephedra sinica contains traces of ephedrine which is a prohibited substance.

Any medicine dispensed from the pharmacy, whether to athletes or officials, had to be on a specially designed prescription form written by an authorised Australian doctor or a registered international team doctor. Even over-the-counter drugs, such as throat lozenges and paracetamol, were required to be on prescription. Patients were given a maximum seven days’ supply of a drug or a complete course of antibiotics.

Prohibited and restricted substances were clearly labelled as such when dispensed, confirmed with prescriber, and the patient counselled accordingly. Athletes were given copies of prescriptions for their own records.

It was challenging trying to counsel non-English speaking patients from many countries. A team of interpreters was always available to help communicate directions to the athletes and to help foreign team doctors liaise with pharmacy.

The pharmacy was also the distribution point in the village for free condoms. This was the first time condoms had been available in an Olympic village, the concept being a trial for future games. Over the two weeks of the Olympic period, tens of thousands were given to the athletes.

In the weeks following the Olympic games, the pharmacy served the athletes of the Paralympic games. There were plans for the athletes’ village after the Olympics. The polyclinic had been designed in such a way that it could be converted into a school after the games. The athletes’ residences were to be sold as private housing, thus creating a new suburb of Sydney.
Once in a lifetime
Working at the Olympic games gave me a once-in-a-lifetime experience, being able to meet Olympic athletes from all over the world and hear their stories. It was challenging to play a part in maintaining the health of the athletes using medicines within the restrictions of Olympic anti-doping rules. Being part of the medical team gave me an inspiring insight into the dedicated lives of the world’s top athletes and valuable experience in the field of sports medicine.