ADDENDUM
S8. Cannabinoids
Background••••	Following receipt of requests from a small number of stakeholders to remove (threenational anti-doping organizations and one sports federation) or review (two anti-dopingorganizations) the prohibited In-competition status of cannabis from the Prohibited List,
the WADA Executive Committee endorsed, during its meeting of September 2021, arecommendation of the WADA List Expert Advisory Group (LiEAG) to initiate a scientificreview of the status of cannabis in 2022.
	At present, the main psychoactive component of cannabis, delta9-tetrahydrocannabinol(THC), is prohibited In-competition and is reported as an Adverse Analytical Finding(AAF) by WADA-accredited laboratories when the urinary concentration- of carboxyTHC exceeds a threshold of 150 ng/mL with a Decision Limit of 180 ng/mL. This
threshold was significantly increased in 2013 from 15 ng/mL in order to minimize thenumber of AAFs In-competition due to potential Use of THC Out-of-competition. Thismeans that with the current threshold, Athletes most at risk of testing positive arethose who have consumed significant quantities of THC close to In-competition Doping
Control or are chronic users.
	The 2021 World Anti-Doping Code (Code) incorporated the new Article 4.2.3 on
Substances of Abuse for purposes of sanctioning under Code Article 10. Substancesof Abuse are specifically identified on the Prohibited List because they are frequently
abused in society outside of the context of sport. In this regard, the LiEAG identified
THC as a Substance of Abuse for the 2021 Prohibited List, meaning that if the Athlete
can establish that the THC use occurred Out-of-Competition and was unrelated to sport
performance, the standard period of Ineligibility is three months, which may be reduced
to one month if the Athlete satisfactorily completes an approved Substance of Abuse
treatment program. While it is too early to evaluate the full impact of this new rule onsanctions for THC, preliminary data from 2021 indicates an increase in one- and threemonth sanctions, suggesting that this provision is being applied.	Under the World Anti-Doping Program, the approach to cannabis on the Prohibited List
has therefore evolved chronologically as follows:
2013: The urinary threshold increased from 15 ng/mL to 150 ng/mL with a Decision
Limit of 180 ng/ ml. This significantly affected the number of AAFs, from an average of
between 400-500 per annum in the years 2009-2012 to fewer than 100 in 2021.
2018: Cannabidiol (CBD) was removed from the Prohibited List, allowing Athletes whowish to use it to have access to the non-psychoactive component of cannabis.
2021: The inclusion of the Substance of Abuse provision in the Code significantly
reduced the length of Ineligibility sanctions from a potential two (or even four) years
previously to three (or even one) month(s) today for Athletes that can establish that theTHC use occurred Out-of-Competition and was unrelated to sport performance. UnderArticle 9 of the Code, the Athlete will still lose their medal, prize and result.
7The Review Process:•	Since September 2021, the LiEAG, which is composed of external, international expertsin pharmacology, forensic toxicology, drugs of abuse, analytical science, pharmacy,sports medicine, chemistry, endocrinology, internal medicine, regulatory affairs, peptides
and growth factors and hematology embarked on a full de novo review of the status ofdelta9-tetrahydrocannabinol (THC) in sport. This extensive review focused on the threecriteria set forth by Article 4.3 of the 2021 Code, namely:a. Medical or other scientific evidence, pharmacological effect or experience that thesubstance or method, alone or in combination with other substances or methods, has
the potential to enhance or enhances sport performance;
b. Medical or other scientific evidence, pharmacological effects or experience that the Useof the substance or method represents an actual or potential health risk to the Athlete;
c. WADA’s determination that the Use of the substance or method contravenes thespirit of sport described in the introduction to the Code.

••••	Under Code Article 4.3, a substance or method must meet at least two of these threecriteria to be considered for inclusion in the Prohibited List.
Two subgroups of members of the LiEAG were formed, one to evaluate the effects ofTHC on performance enhancement (LiEAG-PE) and the other to assess the health risks(LiEAG-H). All existing scientific and medical publications related to these two topics
were reviewed, as well as testimonials from Athletes who were/are cannabis users,available publicly, including in published surveys.
This scientific literature review was subsequently discussed with four world-renowned
independent, external international experts (Ad-Hoc THC Expert Group) specialized
in the pharmacology, toxicology, psychiatry and behavioral properties of THC andcannabinoids, to ensure that all relevant publications had been included and that all
relevant scientific and medical aspects had been appropriately evaluated. The experts
confirmed that the information review had been extensive and that all relevant dataand aspects of the impact of THC on health and performance enhancement had been
properly examined.
With respect to the Spirit of Sport criterion, the LiEAG Chair consulted with the WADA Ethics
Expert Advisory Group (Ethics EAG). The Ethics EAG considered cannabis Use, at this time,
to be against the Spirit of Sport across a cluster of areas listed in the Code, in particular:•Health•Excellence in Performance•Character and Education•

Respect for rules and laws•

Respect for self and other participants

They also noted that:•Further research should be undertaken or supported in relation to Athletes’ perceptionsof cannabis Use but also in relation to its potential (including placebo-induced)
enhancing effects. These are areas of uncertainty owing to a lack of robust evidence.

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Levels to trigger an Anti-Doping Rule Violation In-competition are such that they would beproblematic on medical grounds for a competing Athlete, or indicative of a chronic habitualuser. The present rule is not, as sometimes perceived or represented, an excessive incursion
into private lifestyles. Nevertheless, and mindful of shifting public attitudes and laws incertain countries, the weight of evidence and argument, along with broad international
restrictive regulatory laws and policies, supports the continuance of cannabis on theProhibited List at this time.
The LiEAG Chair also consulted with the members of the WADA Athlete Committee to seek
their opinions on the Use of cannabis in sport. The meeting reflected the range of opinions
and views of the Athlete community.
In total, there were 10 consultative meetings held prior to the latest meeting of the LiEAG on25-26 April 2022:•three by the LiEAG-PE•

two by the LiEAG-H•

one between the LiEAG Chair and the Athlete Committee Chair•

one between the LiEAG Chair and the Athlete Committee•

one between the LiEAG Chair and the Ethics EAG•

one between the Ad-Hoc THC Expert Group and the LiEAG-PE•

one between the Ad-Hoc THC Expert Group and the LiEAG-H

Conclusions:
After a thorough assessment and discussion under WADA Code Article 4.3, the LiEAG
concluded that:a. There is compelling medical evidence that Use of THC is a risk for health, mainly
neurological, that has a significant impact on the health of young individuals, acohort which is overrepresented in Athletes.
b. The current body of objective evidence does not support THC enhancement ofphysiological performance, while the potential for performance enhancement throughneuropsychological effects still cannot be excluded.
c. In consideration of the values encompassed by the Spirit of Sport as outlined by
the Ethics EAG, and noting in particular that respect for self and other participants
includes the safety of fellow-competitors, the Use of THC In-competition violates
the Spirit of Sport.
Based on these three criteria defined by the Code, on the scientific evidence available,
THC meets the criteria to be included on the List.

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Future considerations:••

These conclusions are based on the currently available scientific literature. From theextensive review conducted, it was evident that there is a lack of robust studies evaluating
the performance enhancing effects of THC at both the physical and mental level. While
anecdotal, self-reported evidence is available, further clinical studies are required torigorously determine the neuropsychological impact of THC on performance. However, it
is also acknowledged that such studies may be difficult to design. For example, it would
require enrolling volunteers actively consuming THC, which in most countries is illegal; itwould not be a truly blinded placebo study because the subject would feel the effect of
THC leading to possible positive bias (to show it has performance enhancing effects andthus should be prohibited) or negative bias (to support exclusion from the List); it would bedifficult to re-create the stress of a competition; and it is very unlikely that high level Athletes
could be included as volunteers. Therefore, only those using cannabis and in regions whereTHC use is legal could be recruited, and in an Out-of-competition setting, with a risk of
positive or negative bias.
As with all substances that are prohibited In-competition only, Athletes in regions wherecannabis use is legal are advised to refrain from consuming cannabis for a number of days
before the start of competition.

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